Healthcare Mentor Checklist

HEALTHCARE MENTOR CHECKLIST

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Mentor & Session Details

Session Date:    Session Type: Initial Follow-up In-person Virtual/Phone

Goals, Strengths & Action Items

Documented patient strengths observed during session (select all that apply):

Motivation to change Social support Medication adherence history

Clinical Safety & Risk Assessment

During this session the mentor assessed for immediate safety concerns and risk factors (select all that apply):

Suicidal ideation Homicidal ideation Self-harm behavior

Medications & Allergies

Medication adherence concerns identified: Yes No

Social Needs & Referrals

Referrals or resources provided (select all that apply):

Primary care Behavioral health Substance use services Housing / shelter

HIPAA Authorization & Consent

By signing below, Patient Name authorizes the healthcare mentor and the mentor's supervising clinical staff to:

• Access and discuss relevant medical information necessary to provide mentoring services and coordinate care.
• Communicate with listed emergency contacts and referral resources as needed for care coordination.
• Document session content and store it in the patient's clinical or program record. Confidential information will be protected except as required by law or to prevent imminent harm.

The patient understands that this authorization may be revoked at any time in writing, except to the extent that action has already been taken in reliance on it. Limits to confidentiality include mandatory reporting of abuse, threats of harm to self or others, and other disclosures required by law.

I consent to routine communications (phone, voicemail, text message) at the contact numbers provided for appointment reminders and care coordination: Yes No

Authorization Expiration Date:

Mentor Assessment Summary

Additional notes and actions assigned to mentor:

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