TSN Peer Visitation Request Form

Thank you for your interest in the Trauma Survivors Network Peer Visitation Program!


Our goal is to assist current patients through the acute phase of their coping journey by matching them with a Trauma Survivor who can help provide support, resources, mentorship, and companionship.


If you are a patient (or have identified a patient) who may benefit from a bedside visit from a peer survivor of trauma, please fill out the form below and we will return your request as soon as possible.


If you would like TSN to provide resources but are unsure if the patient would like a peer visit, or if they've declined a peer visit but are still interested in TSN, please Tiger 'STC Trauma Survivors Network (TSN) Coordinator,' email TSN@umm.edu, or call 410-328-5545.

Has the patient and/or POA verbally consented to peer visitation, including sharing of health information for the intake/matching process?*

If there are any large barriers to obtaining consent, please indicate that below (without disclosing any Protected Health Information) and we will be happy to reach out to further discuss. Otherwise, please obtain verbal consent for peer visitation from the patient/POA.

Requester Information

Select or enter value
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Phone

Patient Information

Patient's current unit*
Patient's current length of hospitalization*
Patient's anticipated discharge timeframe
Patient's age*
Patient's mechansim of injury*

(I.e.: prefers males, Spanish-speaking only, hard of hearing, cognitive impairment/delay, etc.)

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