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Peer Support Intake Form - Free Healthcare Template | ZenBuild | ZenBuild

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Peer Support Intake Form

Collect background information from individuals seeking peer support services for mental health or substance use recovery. Helps peer support specialists personalize their approach and set meaningful goals with each client. Supports behavioral health programs.

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Peer Support Intake Form

Complete this intake form to begin your peer support services.

Your First Name (Preferred Name)*

Primary Reason for Seeking Support*

Are you currently receiving other mental health services?*

Yes – therapy or counselingYes – medication managementYes – bothNo – peer support is my first step

How would you rate your overall wellbeing right now?*

What goals do you hope to work on with your peer specialist?

Template Details

CategoryHealthcare

IndustryHealthcare

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healthcarepeer supportmental healthbehavioral healthrecovery