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  • Peer Support Interaction Form

  • {clientFnameLname}
    {dateOf}

  • Information & Concerns
    select all that apply


  •








  • {clientFnameLname}
    {dateOf}

  • IMMINENT DANGER:

    • Locate client's location via IP Address
    • Contact Emergency Services  (add the client city or zip code to the search parameters)
    • Schedule a Follow-Up
    • Flag the Call Report so Program Director can review it

  • LOW - MODERATE RISK: 

    • Support the client in creating a self-care / safety plan

  • MODERATE - HIGH RISK:

    • Connect the client to a crisis clincian 
    • Support the client in creating a safety plan 
    • Schedule a Follow Up

  • HIGH RISK:

    • Connect the client to a crisis clinician
    • Schedule a Follow Up
    • Flag the Call Report so the Program Director can review it

     

  • VERY LOW RISK: No safety concerns

  • LOW RISK: Not currently in danger

  • {clientFnameLname}
    {dateOf}

  • Remember to add to LetsTalk Calendar »

  •  -  -
    Pick a Date
  •  :

  • {clientFnameLname}
    {dateOf}

  • Remember to email these resources to the client :-)


  •

  • Facebook Support Groups

    view recommended groups »


  •

  • {clientFnameLname}
    {dateOf}

  • Search Directory »

  • {clientFnameLname}
    {dateOf}

  • Search crisis center & suicide hotline numbers

    Contact Emergency Services
    add the client city or zip code to the search parameters

     

  •  

    Remember to review before clicking submit!

     

    CALL INFO


    Date of Interaction {dateOf}

    Contact Type {contactType}

    Follow Up? {followUp}

    FLUP Submission ID # {flupSubmission}

    New Client? {NewClient}

    Client Name {clientFnameLname}

    Client Email {email}

    Concerned Other - Is this person reaching out about someone else? {concernedOther139}

    Name of the person that this individual is concerned about (if known): {nameOf137}

    Provider Name {typeA}

    INFORMATION NEEDS


    REPRODUCTIVE HEALTH: {reproductiveHealth}

    MEDICATIONS: {medications}

    MENTAL HEALTH: {mentalHealth}

    ADDICTION: {addiction}

    THBSO: {thbsoremoval}

    INFORMATION NEEDS: {informationNeeds}

    CO-EXISTING CONDITIONS: {coexistingConditions}

    SAFETY CONCERNS: {safetyConcerns}

    INTERPERSONAL CONFLICT: {interpersonalConflict}

    CALL DETAIL

    Data:

    {data}

    Assessment:
    {assessment}

    Plan:
    {plan}

    Chat URL:
    {conversationLink}

     

    RISK ASSESSMENT


    Are you thinking of suicide? {areYou}

    Have you thought about suicide in the last two months? {areYou64}

    Have you ever attempted to kill yourself? {haveYou65}


    DESIRE: {typeA53}
    INTENT: {desire}
    CAPABILITY: {intent}
    SUBSTANCE USE: {capability}
    BUFFERS / SOCIAL SUPPORT: {substanceUse}

    Risk Score: {number}

    FOLLOW UP


    Schedule follow up? {scheduleFollow117}

    Scheduled for: {date118} at {time} EST

    Notes for Follow Up: {notesFor}
     

    RESOURCES


    Shared Resources: {sharedResources}

    Facebook Support Groups: {facebookSupport}

    REFERRALS


    Providers:
    {referralsGiven}

    Emergency:
    {referralsGiven129}

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