Peer Counseling Referral Form

Today's Date:

Name:

Email Address:

Referring Person/Agency

Relationship to Participant:

First Name:	Last Name:	Middle Initial:
Age:	Date of Birth:	Email:
Address:
Phone:	When is the best time to call:
Does anyone live with the participant, if so who:
Are there any pets in the home, if yes, will they be secure and what type of pet:
Preferred Contact Method: Phone Email Mail	Primary Language:
Does Participant need an Interpreter:

Emotional support Isolation/Loneliness Coping with illness/disability Grief or loss Other -

Please describe the concern or reason for referral:

Additional Notes or Relevant Information:

Are there any permanent disabilities we should know about, e.g. hearing impaired, blindness, or wheelchair bound:

The participant has agreed to be contacted by a peer counselor.