Intervention Report Date(Required) MM slash DD slash YYYY Peer Supporter Name(Required) Time First Contacted(Required)(Approx) 24hr Format – 00:00hrs Hours : Minutes Time Contact Ended(Required) Hours : Minutes (Approx) 24hr Format – 00:00hrs Initially Contacted By(Required) Phone Text Message Email In Person Other Initially Contacted By – Other(Required) Type(Required) Critical Incident Alcohol Dependency/Abuse Substance Abuse Financial Issues Domestic Relationship Issues General Mental Health (Stress, Depression, Anxiety) Other Type – Other(Required) Type of Activity(Required) 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(Required) FF Specialist FAO LT. Capt. Chief Level Officer (DC or Higher) Dispatcher -ECC Family Member – Civilian Other Rank(s) of member(s) involved – Other(Required) Number of Persons Involved(Required)Initial Disposition(Required) Information Sent Questions Answered PST Alerted Clinician Alerted Referral Made for Treatment Taffy Outreach Follow Up Other Initial Disposition – Other(Required) Referral InformationReferral To: PEAP Emergency Department Counselor IAFF Center for Excellence Pinpoint Behavorial Other Referral To – Other Jurisdiction(Required) 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 InformationNumber of Peer Supporters