Healthcare Peer Plan

HEALTHCARE PEER PLAN

1. Client / Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

2. Emergency Contact

Relationship:    Phone:

3. Insurance & Primary Care

Policy Number:    Group Number:

4. Relevant Medical History

5. Peer Support Service Description & Scope

This Healthcare Peer Plan documents peer support activities, goals, and agreed practices. Peer support is provided by trained peers to assist with recovery, coping skills, community integration, and advocacy. Peer support is not psychotherapy or medical treatment and is not a substitute for clinical care.

6. Goals, Action Steps, and Responsibilities

The following goals are collaboratively developed, measurable where possible, and reviewed regularly. Responsible parties include the peer supporter, the client, and other identified supports.

Target Date:    Responsible:

Target Date:    Responsible:

7. Frequency, Duration, and Location

Planned frequency of peer contacts:    Estimated duration of plan:

8. Crisis & Safety Plan

Crisis Contacts: Name:    Phone:

9. Confidentiality, Limits, and Mandatory Reporting

Peer support contacts are confidential except where disclosure is required by law or professional obligations. Limits to confidentiality include: imminent risk of harm to self or others; suspected abuse or neglect of a child, dependent adult, or elder; court order or lawful subpoena; threats of violence; and other mandatory reporting obligations under applicable law. Information disclosed under these exceptions will be limited to that which is necessary.

10. Risks, Benefits, and Relationship Boundaries

Benefits may include increased coping skills, social connectedness, and navigation support. Risks may include emotional discomfort when discussing difficult topics. Peer supporters are not clinical therapists, do not provide medical advice, and will maintain professional boundaries. If clinical intervention is needed, referral to appropriate clinical services will be recommended.

11. Authorization for Information Exchange

By signing below, the patient authorizes exchange of relevant information between peer support staff and the entities listed below to coordinate care and support goals. The scope of information to be shared may include peer plan goals, crisis planning information, and coordination notes. This authorization does not authorize disclosure of psychotherapy notes unless expressly indicated.

Information to be exchanged (check applicable): Care coordination notes Crisis/safety plan Referrals and appointments

Expiration of authorization:

Revocation: The patient may revoke this authorization at any time by providing written notice to the agency or peer support program, except to the extent actions have already been taken in reliance upon this authorization.

12. Termination, Review, and Amendments

This plan will be reviewed at regular intervals and may be amended by mutual agreement. Either party may request modification or termination of the peer plan. The program may discontinue services for non-participation, breach of safety, or behavior inconsistent with program rules, following a documented process.

13. Acknowledgment and Consent

I acknowledge that I have read and discussed this Healthcare Peer Plan with a peer supporter, that my questions have been answered, and that I understand the nature, purpose, benefits, and limits of peer support services described herein. I understand that I may withdraw consent at any time as set forth above.

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