Healthy Building Institute of America

CPSM Interaction Log & Care Coordination Forms

Certified Peer Support Mentor · Daily Log · Weekly & Monthly Reports

800.781.7986 · www.hbiatoday.com · All records are confidential

□ Interaction Log □ Medical □ IEP / IAQ □️ Remediation ⚠️ Safety □ Weekly □ Monthly

SECTION A — SESSION INFORMATION

Date

Time Started

Time Ended

Session Duration

Session # with This Peer

Contact Method — check all that apply

Phone CallVideo — ZoomVideo — FaceTimeIn-PersonEmailText MessageHBIA PortalOther

Session Summary

SECTION B — CPSM INFORMATION

CPSM Full Name

CPSM ID #

Phone

Email

Team Lead / Supervisor

SECTION C — PEER INFORMATION

Peer Full Name

Preferred Name

Phone

Email

Home Street Address

City

State

ZIP

Preferred Contact

PhoneTextEmailVideoIn-Person

Consent

OK to leave voicemailOK to leave message with others

SECTION D — EMOTIONAL STATE ASSESSMENT

CPSM Emotional State — Check all that apply

Positive / Supportive

HopefulEncouragedEmpoweredCalmGratefulConnectedConfidentMotivatedSatisfiedCompassionateEnergizedGrounded

Neutral / Reflective

NeutralReflectiveCautiousUncertainTired / FatiguedDetachedPensiveProcessing

Challenging / Difficult

SadFrustratedAngryAnxiousOverwhelmedConfusedDistressedTriggeredDepletedGrievingHelplessWorriedNumbBurned OutRe-ActivatedProtective

CPSM Emotional Notes

PEER Emotional State — Check all that apply as observed

Positive / Hopeful

HopefulRelievedGratefulCalmEncouragedOpenTrustingMotivatedHappyOptimisticEmpoweredConnected

Neutral / Unclear

NeutralUncertainCautiousGuardedAmbivalentTired / FatiguedDistractedFlat Affect

Challenging / Distressed

SadCrying / TearfulAngryFurious / RagefulFrustratedAnxiousPanickedOverwhelmedConfusedHopelessDesperateGrievingIn ShockNumbDistrustfulIsolatedAshamedScaredTraumatizedSuicidal Ideation ⚠️Harm to Others ⚠️

⚠️ If "Suicidal Ideation" or "Harm to Others" is checked — go to the Safety tab immediately and contact your HBIA Team Lead.

Peer Emotional Notes

SECTION E — RESOURCES SHARED

HBIA Resources

HBIA Guide: SBS OverviewHBIA Guide: Mold & MoistureHBIA Guide: IAQ BasicsHBIA Guide: Lead & AsbestosHBIA Guide: Water QualityHBIA Medical NetworkHBIA Environmental / IAQ NetworkHBIA Remediation DirectoryHBIA Community NavigatorHBIA Website

External / Crisis Resources

988 Suicide & Crisis LifelineNational DV Hotline: 1-800-799-7233FEMA / Disaster AssistanceHUD / Housing AssistanceLocal Health DepartmentLegal Aid ServicesState Tenant RightsOther — see notes

Additional Resources Shared

SECTION F — ACTION ITEMS & CARE PLAN

Action Item / Task	Responsible	Target Date	Status
			--PendingIn ProgressCompletedDeferred
			--PendingIn ProgressCompletedDeferred
			--PendingIn ProgressCompletedDeferred
			--PendingIn ProgressCompletedDeferred
			--PendingIn ProgressCompletedDeferred

Next Steps / Follow-Up Plan

Next Contact Date

Next Contact Time

Additional Notes

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SECTION J — SAFETY & ESCALATION LOG

⚠️ Complete if ANY safety concern was identified. Contact your HBIA Team Lead immediately.

Safety Concerns — Check all that apply

Self-harm or suicidal ideationIntent to harm another personActive abuse or domestic violenceChild in immediate dangerAdult in immediate dangerHopelessness with specific planUnable to meet basic needsOther — describe below

Description — What was said or observed

Team Lead Contacted

Date / Time Contacted

Actions Taken / Escalation Steps

Emergency: 988 (Crisis Lifeline) · 1-800-799-7233 (DV Hotline) · 911

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CPSM WEEKLY SUMMARY REPORT

Week of (Monday)

Week Ending (Sunday)

Report Submitted

CPSM Name

CPSM ID #

Total Sessions

Unique Peers

Total Hours

Escalations

CPSM Weekly Wellbeing

Overall emotional state

Stable / WellMostly PositiveMixed / VariableMostly ChallengingBurned OutTriggered

Hardest moment this week

Most encouraging moment

Self-care completed

Post-call debriefExercise / movementSupport system timeOwn therapy sessionTeam Lead debriefRest / sleep recoveryJoyful activityReduced hours

Supervision notes

Peer Trends

HopefulAnxiousOverwhelmedSad / GrievingAngry / FrustratedConfusedPositive ShiftCrisis Concern

Resources most shared

Notes for Team Lead

CPSM Signature

Date Submitted

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CPSM MONTHLY SUMMARY REPORT

Month / Year

Report Period

Report Submitted

CPSM Name

CPSM ID #

Total Sessions

Unique Peers

Total Hours

Escalations

Monthly Wellbeing

Consistently WellMostly PositiveVariableMore Challenging Than GoodBurnout RiskConsidering Stepping Back

What sustained me

What depleted me

Peer Outcomes

Overall peer wellbeing trends

Top resources / referrals

Peer success story (de-identified)

Ongoing concern needing leadership awareness

Goals & Renewal

Goals met? YesPartiallyNo

Goal review notes

Goals for next month

Notes for HBIA Leadership

CPSM Signature

Date Submitted

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