PEER SUPPORT Contact Report

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 *
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 Follow0Up 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.
Should be Empty: