PEER SUPPORT Contact Report
This form will be emailed directly to Dr. Rodgers for data tabulation and record keeping. Any questions call 505-250-8236.
Person filling out this form
First Name
Last Name
Department or Agency Filling Out this Contact Report
*
Please Select
AAS
AFR
BCFD
BCSD
Carlsbad FD
DACFR
GCSD
Los Alamos FD
Los Alamos PD
Los Lunas PD
Los Lunas FD
Lincoln County
MDC
Otero County Sheriff
Rio Communities FD
Roswell PD/FD
RRFD
RRPD
SFFD
SFCFD
SFPD
SJCSO
Taos PD
Tesuque PD
VCFD
VCSD
Other
If OTHER please type agency or department.
Date of Contact
*
-
Month
-
Day
Year
Date
Time of Day of Contact
0000-0800
0815-1200
1215-1600
1615-2000
2015-2400
Amount of Time of the Contact
0-30 minutes
31-60
61-90
91-120
More than 121
Type of contact
In-Person
Phone
Zoom or Face Time
Text or Email
Context for Contact
Initial Contact
Follow Up Contact
PEER Assessed Severity/Risk Level of the Contact
Low (Green)
Medium (Yellow)
High (Red)
Consultation with Mental Health Provider Needed
Yes
No
Referral for Other Services (counseling, medication, etc.)
Yes
No
Brief Contact Description WITHOUT Identifying Information
INTERVENTION SEEKER- # of Years of Service
0-5 years
6-10
11-15
16-20
21-30
30+
Reason Individual was Seeking PEER Support
Relationship Issue/Divorce
Traumatic Call/Event
Death Call/ Pediatric Death
Death Coworker, Friend, Family Member
Personal or Family Member Medical Issue
Home Stress
Work Conflicts
Suicide or Depression
Stress and burnout
Retirement or Career Issues
PTSD or Anxiety
Alcohol or Drug Issues
Military Issues
Pet Death or Medical issue
Spiritual Crisis
Preventative contact
Other
If OTHER please specify
Any additional notes or comments.
Submit
Should be Empty: