Peer Team Engagement Form (Demo) Enter Email Address to Send a Copy of This Form to:(Required) Date MM slash DD slash YYYY Time First Contacted(Approx) 24hr Format – 00:00hrs Hours : Minutes Initially Contacted By Phone Text Message Email Other Initially Contacted By – OtherType Critical Incident Alcohol Dependency/Abuse Substance Abuse Financial Issues Domestic Relationship Issues General Mental Health (Stress, Depression, Anxiety) Other Type – OtherType of Activity PST contacted members A member reached out to PST for assistance (Themselves) A member contacted PST to make a referral for someone else A family member contacted PST to make a referral for a member Other Rank(s) of member(s) involved FF Specialist FAO LT. Capt. Chief Level Officer (DC or Higher) Dispatcher -ECC Family Member – Civilian Other Rank(s) of member(s) involved – OtherNumber of Persons InvolvedInitial Disposition Information Sent Questions Answered PST Alerted Clinician Alerted Referral Made for Treatment Other Initial Disposition – OtherReferral InformationReferral To: PEAP Emergency Department Counselor IAFF Center for Excellence Other Referral To – OtherJurisdiction CFD PST of CFD CFD PST for Cincinnati ECC CFD PST for Ohio Agency (Tristate PST) CFD PST for N.KY Agency (Tristate PST) CFD PST for IN Agency (Tristate PST) CFD PST for Ohio Agency (OAPFF PST) Other Other InformationNotes:
