Peer Check-In Report
This form should be filled out after every peer check-in.
Who is submitting this Jotform?
Cassandra
Kayla
Alexia
Yo Sis
TaTa-Nisha
Other
Other
Peer Name
*
Date
*
County
Date of Birth
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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18
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20
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29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2006
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2002
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2000
1999
1998
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1996
1995
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1985
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1983
1982
1981
1980
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1971
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1968
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1941
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
What is their gender?
Male
Non-Binary
Female
Were they over 18?
Yes
No
Ethnicity:
White
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic/Latino
American Indian or Alaska Native
Other
What type of support was provided?
Family Support
Housing Support
Employment Support
Community Resource Referral
Treatment Referral
Peer Support
Did we provide transportation?
No
Yes
Other
1-on-1 Peer Interaction?
Phone
In-Person
Zoom
Outreach
Notes
ORS: Outcome Rating Scale
Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life. One indicates low levels and 10 indicates high levels.
Individual (Personal well-being)
1-10
Interpersonal (Family, close relationships)
1-10
Social (Work, school, friendships)
1-10
Overall (General sense of well-being)
1-10
Total Score
Submit Form
Should be Empty: