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Peer Recovery Coaching Note

Document peer support contacts and outcomes.

Kura Solution

Appendix Q — Peer Recovery Coaching Note

Document peer support contacts and outcomes.

Header

Resident Name *

Date of Contact *

Duration (minutes)

Service Type

Recovery Goal Addressed

Intervention Provided

Resident Strengths / Progress

Barriers / Challenges

Next Steps

Signatures

Peer Coach Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Peer Coach Printed Name *

Date *

Supervisor (if required) Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Supervisor (if required) Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.