Healthcare Peer Support Form

HEALTHCARE PEER SUPPORT FORM

Patient Information

Patient Name:    Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History & Current Status

Peer Support Needs and Goals

Preferred contact method: Phone Text Message Email In-person

Are there current safety concerns (harm to self or others) or active suicidal ideation? Yes No    If yes, brief description:

Consent, Confidentiality & Limits

I understand that peer support is provided by trained peers and is intended to offer emotional support, mutual aid, practical guidance, and assistance with accessing resources. Peer support is not a substitute for licensed mental health therapy, medical diagnosis, or crisis services. I understand that peers do not provide clinical treatment.

Confidentiality: Information shared with peer support staff will be kept confidential except where disclosure is required or permitted by law. Exceptions include:

• Reasonable belief of imminent risk of harm to self or others;
• Suspected abuse or neglect of a child, elder, or dependent adult;
• Legal process such as a court order or subpoena;
• When a release of information is signed authorizing disclosure to named individuals or agencies.

By checking the box below I acknowledge that I have read and understand the confidentiality provisions and limits described above. I acknowledge

HIPAA and Privacy: I acknowledge that I have been informed about the privacy practices that govern how my information may be used and disclosed in peer support services. I understand that protected health information may be used for care coordination and program administration as described in this form. I acknowledge

Authorization to Share Information

I authorize peer support staff to share information about my participation, safety concerns, and relevant service coordination with the following persons or agencies as needed to support my care:

Purpose of disclosure: care coordination, safety planning, appointment scheduling, and referrals.

I understand that I may revoke this authorization at any time in writing, except to the extent that disclosures have already been made in reliance on this authorization. Revocation must be submitted to the program in writing.

Session Agreement & Recording Consent

Session frequency and format will be mutually agreed upon. I consent to receive peer support via the methods indicated above. I understand that sessions are intended to be supportive and strengths-based.

Recording sessions: I understand that sessions will not be recorded without my explicit consent. By checking the box below I consent to audio/video recording of peer support sessions as specified: I consent to recording I do not consent to recording

Acknowledgement and Certification

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I have had the opportunity to ask questions and have them answered. I voluntarily consent to participate in peer support services under the terms described in this document.

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