CCS/CRS - Recovery Dane Peer Support Specialist Referral

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A Certified Peer Specialist is a person who has had their own experience of struggling with mental health and/or substance use, and, matched with formal state-sponsored training and continuing education, serves peers who are facing their own emotional challenges. Peer support is a 100% voluntary service driven by the peer's vision and priorities and focuses on the emotional connecting/sharing between two people who have their own experiences of coping with mental health/substance use challenges. Peer Support should not be used for or replace services/tasks such as errand-running or use of transportation.

Note: "Peer" is defined as the person being referred for peer support.

Email *

Date of Referral *

YYYY

Is the client in CCS or CRS? *

CCS

CRS

Referring Staff Name *

Referring Staff agency affiliation & phone number *

Is the referring staff the person who can add services to a peers plan?

Yes

Unknown (this will result in follow-up from Recovery Dane)

Clear selection

Peer Dane County ID number *

Peer Identified Name and Pronouns *

Peer Legal Name *

Peer Date of Birth *

YYYY

Peer Address

Peer Email Address

Peer Phone Number *

Peer Support Focus or Need *

Has the peer worked with a Certified Peer Specialist before? *

Yes

If possible, would the peer prefer to meet with a peer specialist that shares an aspect of lived experience such as cultural background, gender identity/experience, or racial identity? If not applicable, please answer N/A.
*

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