Form Follow-up Question Follow-up Question Follow-up Questionnaire

MI/SP Counselor Follow-up Questionnaire
OMB No. 0930-0274
Expiration Date: XX/XX/2016
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0274. Public
reporting burden for this collection of information is estimated to average 10 minutes per client per year, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057,
Rockville, Maryland, 20857.

MI/SP Counselor Follow-up Questionnaire
FORM A: COUNSELOR INFORMATION
To be completed once by each counselor who makes follow-up calls.
Center:
Counselor’s Name:

(Will be replaced by ID #)
(Will be replaced by ID #)

Today’s Date:
1. How long have you worked as a telephone crisis worker? (Check one and give details)
Less than 1 year – Number of months
1 year or more – Number of years:
2. How long have you been conducting follow-up calls? (Check one and give details)
Less than 1 year – Number of months:
1 year or more – Number of years:
3. What is your employment status at your center?
Paid employee
Volunteer
Both
4. What is your highest level of education? (check one)
Less than high school
High school graduate or GED
Some college or technical school
College graduate
Graduate school (e.g., M.S., M.S.W., Ph.D., M.D.)
5. Have you completed training in ASIST (Applied Suicide Intervention Skills Training)?
Yes – Date(s) of training:
No
6. Do you use “safety planning” protocols in your crisis intervention work at your center?
Yes
No

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MI/SP Counselor Follow-up Questionnaire
7. What is/are the source(s) of the safety planning protocols you currently use? (please
check all that apply)
Safety planning protocols derived from ASIST
Safety planning protocols developed at your center
Safety Planning Intervention (SPI) webinar/DVD (provided by SAMHSA)
Safety planning protocols developed by Drs. Barbara Stanley and Gregory
Brown for the Veterans Administration (adopted prior to SAMHSA training)
Safety planning protocols from another source:
Using safety planning protocols, but unsure of the source
Not using safety planning protocols at this time

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MI/SP Counselor Follow-up Questionnaire
FORM B: CLIENT INFORMATION & FOLLOW-UP CALL LOG
Instructions:
This form is to be filled out for each client (caller to hotline or ED/hospital discharge, and all
other clients, i.e., MHC clients) enrolled in your center’s follow-up program. Submit form to
evaluation team after case is closed.
When you save this document, please use the following convention for naming your file: six digit
date, underscore, last four digits of primary phone number provided for follow-up, underscore,
initials of the counselor submitting the form. The complete file name should look like this:
091911_1234_AB.doc (for example).
1. Center:

(Will be replaced by ID#)

2. Client’s Initials:

(Will be replaced by ID#)

3. Last 4 digits of client’s primary phone number provided for follow-up:

I. CIRCUMSTANCES OF REFERRAL FOR FOLLOW-UP
4. Referral Source:
Hotline call

If yes:

Lifeline call

Call to center’s other line (local, 211, etc.)

Hospital referral
If yes, from:

Emergency department

Inpatient unit

Name of hospital:
Other

If yes, referral came from where?

5. Date of Referral for Follow-up:
(i.e., date of hotline call or hospital discharge)
6. What were your criteria for offering follow-up to this client? (check all that apply)
Suicidal ideation within 48 hours of referral

Absence of buffers

Moderate to high suicide risk

Client not in treatment

Suicide attempt within past week
Other:
7. Has this client accepted follow-up from your center before?
Check here if this client has been enrolled in your center’s follow-up before (i.e., the
client’s previous case was closed, Form B was sent, and the case is now being
reopened)

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MI/SP Counselor Follow-up Questionnaire

II. CLIENT’S DEMOGRAPHICS
8. Gender:

Male

Don’t know

9. Age: (in years):
10. Ethnicity:

Don’t know

Female

Hispanic

Don’t know

Not Hispanic

11. Race (check all that apply):
Asian/Pacific Islander

White/Caucasian

Black/African American 



Other:
Don’t know

Native American/Alaskan Native
12. Ever Served in US Military?

Yes

If Yes, check all that apply:
Veteran

Don’t know

No

Current military service

Reservist

Active Duty
Don’t know

National Guard

Served in combat zone or on peacekeeping mission?

Yes

Don’t know

No

If Yes, where and when?
13. Employment Status (check all that apply)
Employed Full Time
Employed Part Time


Unemployed

Homemaker


Retired

On Disability



Don’t know

14. Household Composition (check all that apply)
Spouse/Partner
Children 


Parents



Other Family Member(s)

Homeless

Non-Family Member(s)

Don’t know

Lives Alone

15. Does client have medical insurance?

Yes

No

Don’t know

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MI/SP Counselor Follow-up Questionnaire

III. BASELINE SUICIDE RISK & INTERVENTION
These questions are about the call to your center, or the hospital visit, which triggered the
client’s referral for follow-up.
16. Client’s Risk Profile At Baseline
Y

N

DK

Y

Suicidal ideation?

Current substance abuse?

Specific suicide plan?

Prior substance abuse?

Means available?

Social supports?

Expressed intent to die?

Other buffers?

Preparatory behavior?

Current outpatient†mh/bhtx?

Attempt in progress?

Prior outpatient†mh/bhtx?

Prior suicide attempt(s)?
*If yes, how many?
*How recent?

*

N

DK

Prior inpatient mh/bhtx?

**If yes, how many times?

**



Prior ED use for mh/bh issue?
**If yes, how many times?

**



†

Include outpatient psychotherapy/counseling, support groups, 12-step programs, and/or psychotropic
medication prescribed by a psychiatrist or primary care physician.

17. Overall Assessment of Client’s Suicide Risk at Baseline: (choose one)
Low
Moderate
High
Imminent Risk
18. Emergency Rescue at Crisis Call
Was emergency rescue initiated in response to this crisis call?
*If yes: Rescue was initiated:

with client’s consent

Yes*

No

N/A

without client’s consent

19. Hospital Admission at Baseline
Was client hospitalized as a result of this crisis call/ED visit?

Yes

No

Don’t Know

20. Referrals Made at Baseline (during crisis call/hospital/MHC visit) (check all that apply)
Outpatient mh/bh service(s):
No referrals
Other/related service(s):

Don’t know

21. Safety Planning at Baseline
Was safety planning initiated/conducted during this crisis call/hospital/MHC visit?
Yes*
No
Don’t Know
*If Yes: Please list components of client’s safety plan as of the crisis call/hospital visit:

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MI/SP Counselor Follow-up Questionnaire
Sections IV-V apply only to cases where one or more clinical follow-up calls was
completed. For cases not successfully reached for follow-up, skip to Section VI.

IV. DURING FOLLOW-UP (FROM ENROLLMENT TO LAST FOLLOW-UP CONTACT)
22. Follow-up Call Log – Please complete one line below for each completed follow-up call.*
Date of completed
follow-up call*:

Duration of
call (in
minutes):

Risk
assessment
completed?

Safety
Planning
conducted?

MH/BH
referral(s)
made/
tracked?

Client using
MH/BH
service(s)?
Y
N
DK

* Do not include calls with no clinical content, e.g., when client was busy and rescheduled the call for
another time. Please complete Section VIII (optional page) if more than six calls were completed.

23. Risk Profile While Follow-up Was Ongoing
Were any of these present at any point while your center was following this client?
Y

N

DK

Y

Suicidal ideation?

Imminent risk?

Specific suicide plan?

Preparatory behavior?

Means available?

Suicide attempt(s)?

N

DK

Expressed intent to die?
24. Emergency Rescue While Follow-up Was Ongoing
Was emergency rescue initiated by your center at any point during follow-up?
*If yes: Rescue was initiated:

with client’s consent

Yes*

No

without client’s consent

25. Referrals Made While Follow-up Was Ongoing:
Outpatient mh/bh service(s):

No referrals

Other/related service(s):
26. Service Use/Treatment Engagement While Follow-up Was Ongoing:
Please check all services the client made use of while your center was following him/her:


Emergency Department visit for mh/bh issue

No service use



Hospital admission/inpatient treatmentfor mh/bh issue

Don’t know

Outpatient mh/bh service(s):
Other/related service(s):
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MI/SP Counselor Follow-up Questionnaire

V. LAST FOLLOW-UP CONTACT
27. Service Use/Treatment Engagement at Last Follow-up Contact
Please check all services the client was engaged with when follow-up ended:
Inpatient mh/bh facility

No service use

Outpatient mh/bh service(s):

Don’t know

Other/related service(s):
28. Risk Profile at Last Follow-up Contact:
Y

N

DK

Suicidal ideation?

Y

N

DK

Current substance abuse?

Specific suicide plan?
Means available?

Social supports?

Expressed intent to die?

Other buffers?

29. Overall Assessment of Client’s Suicide Risk at Last Follow-up Contact: (choose one)
Low

Moderate

High

Imminent Risk

30. Safety Plan at Last Follow-up Contact
Please list components of client’s safety plan as of the end of follow-up:

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MI/SP Counselor Follow-up Questionnaire

VI. CASE SUMMARY/CLOSURE
NOTE: For the following questions about completed calls, do not include calls with no clinical
content, e.g., when client was busy and rescheduled the call for another time.
31. How many clinical follow-up calls were completed with this client?
32. How many counselors completed clinical follow-up calls in this case?
33. Did the counselor who handled the incoming hotline call also complete one or more followup calls?
Yes
No
N/A
34. Please give name/initials of each counselor who completed a clinical follow-up call in this
case:(names will be replaced with ID#s)
NOTE: If any of these counselors have completed any new crisis training since their last
Counselor Follow-up Questionnaire, please complete Section VII (optional page).

35. Was text messaging/email used during follow-up in this case?

Yes

No

36. Please give the date the case was closed:
37. Please give the reason(s) for closing this case: (check all that apply)
Client’s suicide risk has been successfully reduced
Client has entered treatment
Client has remained in treatment for a designated amount of time
Client declined follow-up, or declined further follow-up
Client could not be reached, or could no longer be reached*
*If yes, please give number of unsuccessful tries before closing:
Caller’s phone disconnected/no longer working
Planned number of follow-up calls has been made
Planned length of time allotted for follow-up has gone by
Other reason:
38. This form was submitted by

(counselor initials) on

(date: MM/DD/YY).

39. Comments:

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MI/SP Counselor Follow-up Questionnaire

VII. NEW COUNSELOR TRAINING (OPTIONAL PAGE)
Please complete this page if any follow-up counselor has received additional training
that has not yet been reported to the evaluation team.
40. New Training of Follow-up Counselors
Counselor 1: (name)
New training in ASIST
Date:
New training in safety planning techniques (other than ASIST)
Date
New training in motivational interviewing techniques (other than ASIST)
Date:
Other new training:
Date:
None of the above
Counselor 2: (name)
New training in ASIST
Date:
New training in safety planning techniques (other than ASIST)
Date
New training in motivational interviewing techniques (other than ASIST)
Date:
Other new training:
Date:
None of the above
Counselor 3: (name)
New training in ASIST
Date:
New training in safety planning techniques (other than ASIST)
Date
New training in motivational interviewing techniques (other than ASIST)
Date:
Other new training:
Date:
None of the above

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MI/SP Counselor Follow-up Questionnaire

VIII. ADDITIONAL FOLLOW-UP CALLS (OPTIONAL PAGE)
Please complete this page if client received more than 6 completed follow-up calls before
the case was closed.
22a. Extended Follow-up Call Log – Please complete one line below for each additional
completed follow-up call.
Date of
completed
follow-up call:

Duration of
call (in
minutes):

Risk
assessment
completed?

Safety Planning
conducted?

MH/BH
referral(s)
made/
tracked?

Client using
MH/BH
service(s)?
Y
N
DK

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