Peer Balance Pre-Screening Form

Name

First NameLast Name

RN/NP role & years in practice

State you’re located in (please write out, no abbreviations)

Phone Number

Please enter a valid phone number.

Email

example@example.com

1. What are you hoping to get out of this session?

2. Have you ever used peer support before?

YesNo

3.What challenges are you currently facing in your nursing career?

4.What aspects of peer support are you most interested in? (Emotional support, burnout prevention, work-life balance, career guidance, etc.

Are you currently experiencing a mental health crisis (such as thoughts of harming yourself or others)?

YesNo

Do you feel emotionally stable enough to participate in a reflective peer support conversation today?

YesNo

Do you understand that Peer Balance sessions are for non-clinical peer support only and not a substitute for therapy or psychiatric care?

YesNo

ATTESTATION:

My signature below certifies that the answers to the above statements are true and correct.

My signature below also indicates that I am aware that my charges for upcoming visit will be charged to my credit card on file. Due to contactless check out procedures, I understand that I will not be asked to sign a receipt but a copy of my receipt will be emailed to me

I, acknowledge and agree to the following:

🔹 Nature of Services
I understand that Peer Balance provides non-clinical peer support coaching sessions designed to offer emotional support, mentorship, and strategies for career sustainability.
These sessions are not a substitute for professional medical, psychiatric, or mental health treatment, and are not intended to diagnose or treat any clinical conditions.

🔹 Confidentiality & Safety
I understand that Peer Balance strives to maintain confidentiality during peer support sessions. However, I acknowledge that confidentiality may be broken in the following situations:

If I disclose any intention or plan to harm myself or others
If I disclose abuse, neglect, or exploitation
If information is required to be shared by law or court order

I understand that Peer Coaches are not acting in a clinical provider role, and that if I disclose safety-related concerns, appropriate steps may be taken to connect me with emergency or professional resources for my protection.

🔹Crisis Situations: I affirm that I am not currently experiencing a crisis that requires immediate professional intervention. If I am in such a state, I understand that it is imperative to seek assistance from emergency services, call 911 or go to the nearest emergency room if I am in danger or experiencing an emergency

🆘 If You Are In Crisis, Please Use One of These Resources Immediately:
📞 988 Suicide & Crisis Lifeline (24/7)
Call or Text: 988
988lifeline.org

📱 Crisis Text Line
Text “HELLO” to 741741 for free, 24/7 support

🏥 Virginia State Crisis Services (RBHA)
Find your local Community Services Board:
www.dbhds.virginia.gov

📋 NAMI HelpLine
Call 1-800-950-NAMI (6264) or text “NAMI” to 62640
nami.org/help

📍 Employee Assistance Program (EAP) through your employer, if available

🔹Consent to Participate: I voluntarily choose to engage in peer support coaching sessions with Peer Balance and consent to participate fully, understanding the scope and limitations of the services provided.

By signing below, I confirm that I have read, understood, and agree to the terms outlined in this attestation.I confirm that I have answered these questions honestly and understand that Peer Balance peer coaching is a non-clinical support service. I understand that if I am in crisis, I should call 911 or 988 for immediate support.

Disclaimer- Peer Balance coaches do not provide therapy, diagnosis, or clinical advice. While some coaches are licensed professionals, they are not acting in a clinical role during peer support sessions.”

Signature

Date Signed

Date