Peer Outreach Referral Form

PARC Peer Outreach Referral Form

Peer Outreach Workers engage homeless or under-housed women and men who often end up in emergency departments due to precarious health, poor primary heath care, a lack of access mental health and addiction services, inadequate housing, poor nutrition, lack of access to and or/ insufficient income. Through accompaniment, advocacy and empathy the Peer Workers assist service users to understand and navigate the system, increase access to community support, and access essential services.

Your Contact Details

Your Name *

Your Phone *

Your Preferred Language *

Specifics

Has the client consented to assistance for Community Peer Worker Assistance? *

Please provide a short physical description of service user (e.g. race, hair color, mobility devices or other distinctive information) *

What type of health, mental health or substance use related difficulty does the person experience? (Please list any relevant diagnostic information) *

Safety concerns (Please list any history of aggression or areas of concerns — at times two peers workers attend apartments where safety is a concern) *

Accompaniment Information: (Please fill in Date, Time, Type of Accompaniment (Primary Health/Mental Health/Social Service or other), Telephone #, Pick-up/Drop of location, the name of contact person, and any other additional Information) *

Referral Source: (Name, Role, Agency, Telephone #) *

Other Support: (Support Worker Name & Contact, Other Agency Contact, Drop In Contact) *

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