Peer Support Intake Form

Peer Support Intake Form — Form Fields

This healthcare template includes 5 fields. 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. Free to customize and use on ZenBuild.

• Your First Name (Preferred Name) (text, required)
• Primary Reason for Seeking Support (dropdown selection, required) — options: Mental health (depression, anxiety, etc.), Substance use / recovery, Housing or life stability, Social isolation, Multiple challenges
• Are you currently receiving other mental health services? (multiple choice, required) — options: Yes – therapy or counseling, Yes – medication management, Yes – both, No – peer support is my first step
• How would you rate your overall wellbeing right now? (rating, required)
• What goals do you hope to work on with your peer specialist? (long text, optional)