Healthy Building Institute of America

CPSM Program Portal

Certified Peer Support Mentor · Complete Program Management

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

□ Peer Intake □ Consent □ Pro Referral ✅ Onboarding ⏱️ Supervised Hrs □ Recertification □ Dashboard □ Resources

PEER INTAKE FORM

Complete during or immediately after the first contact with a new peer.

Intake Date

How Did Peer Find HBIA?— Select --WebsiteProfessional ReferralWord of MouthSocial MediaCommunity EventOther

Peer Contact Information

Full Name

Preferred Name

Phone

Email

Home Address

City

State

ZIP

Dwelling & Presenting Concerns

Dwelling Type— Select --Single Family (Owned)Single Family (Rented)Apartment / CondoTownhouseMobile HomeWorkplaceSchoolOther

Time at Location

Presenting Concerns

Mold / Mold IllnessWater Damage / FloodingIndoor Air QualitySick Building SyndromeLead ExposureAsbestosChemical SensitivityHVAC / VentilationChronic Unexplained IllnessHousing DisputeChildren AffectedOther

Description

Urgency & Assignment

□ Routine□ Elevated□ Urgent

CPSM Assigned

Assignment Date

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PEER CONSENT & CONFIDENTIALITY AGREEMENT

Must be completed before peer support services begin.

Your CPSM IS

✅ A trained volunteer with lived experience in environmental illness

✅ Someone who listens, validates, and believes your story

✅ A bridge to resources and the HBIA community

✅ Bound by strict confidentiality to protect your privacy

Your CPSM IS NOT

❌ A doctor, nurse, therapist, or licensed professional

❌ Able to diagnose conditions or recommend treatments

❌ A lawyer or legal advisor

❌ A crisis counselor — in crisis call 988 or 911

Mandatory Disclosure

Your CPSM must report: (1) Suicidal ideation, (2) Intent to harm others, (3) Suspected child abuse/neglect, (4) Court order.

Your Rights

• End the relationship at any time
• Request a different CPSM
• Be treated with dignity and respect
• File a complaint: 800.781.7986
• Access your records upon request

Consent & Signature

By signing, I confirm I have read and understand this agreement, what a CPSM can/cannot do, and the confidentiality policy. I voluntarily agree to begin peer support.

Peer Name

Signature (type name)

Date

Guardian (if minor)

Guardian Signature

Relationship

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PROFESSIONAL REFERRAL TO HBIA

For medical providers, social workers, attorneys, and housing advocates to refer families to HBIA.

Referring Professional

Name

Title / Credentials

Organization

Phone

Email

Type— Select --PhysicianSocial WorkerAttorneyHousing AdvocateEnvironmental ProfessionalMental HealthOther

Patient / Client

Name

Phone

Email

Address

Reason & Urgency

Mold illnessSBSIAQ concernsWater damageLead / asbestosChemical sensitivityHousing disputeEmotional distress

Details

□ Routine□ Elevated□ Urgent

I confirm consent and understand HBIA provides peer support, not professional services.

□ Submit Referral

CPSM ONBOARDING CHECKLIST

Track every step from application through independent launch.

CPSM Name

Start Date

Overall Progress:

0%

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SUPERVISED HOURS TRACKING LOG

Track 20 required supervised hours. Click "Add Session" to log each one.

CPSM Name

Team Lead

Hours Progress: 0 / 20 hours

0%

#	Date	Hours	Method	Summary / Skills	TL Init.

+ Add Session

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ANNUAL RECERTIFICATION MODULE

Annual recertification required. Complete: policy acknowledgment, competency quiz (≥80%), wellbeing assessment, and Ethics Pledge renewal.

CPSM Name

CPSM ID #

Original Cert Date

Recertification Date

Section 1 — Policy Acknowledgment

I have reviewed all current HBIA policies including Service Agreement, gift policy, confidentiality, and mandatory reporting. I have reviewed updated Interaction Log and reporting requirements. I acknowledge any policy changes communicated since my last certification.

Section 2 — Competency Quiz (≥80% to pass)

□ Submit Quiz

Section 3 — Annual Wellbeing Assessment

Overall wellbeing this year— Select --Consistently Well / StableMostly PositiveVariableSignificant Burnout RiskConsidering Stepping Back

What sustained you?

What support do you need?

Section 4 — Ethics Pledge Renewal

Re-affirm your commitment. Check each item.

Signature

Signature (type name)

Date

Team Lead Approval

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PROGRAM DASHBOARD

Program-level overview for HBIA leadership.

Active CPSMs

Active Peers

Sessions This Month

Escalations

CPSM Roster Status

Active & Serving
8

In Supervised Hrs
2

On Leave / Reduced
1

Recert Due
1

Peer Emotional Trend

Most Common Positive

HopefulRelievedGrateful

Most Common Challenging

OverwhelmedAnxiousFrustrated

Sessions by Method

32

Phone

24

Zoom

12

In-Person

10

Email

6

Text

3

Other

Top Resources Shared

1. HBIA Guide: Mold & Moisture

2. HBIA Medical Professional Network

3. HBIA Remediation Contractor Directory

4. HBIA Guide: IAQ Basics

5. 988 Suicide & Crisis Lifeline

Leadership Notes

Notes

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PEER RESOURCE DIRECTORY

Living document. Star (⭐) peer-recommended resources in Notes. Update monthly.

CPSM Name

Last Updated

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