Form Individual_Family_ Individual_Family_Encounter_Form

Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)

3_20_15_Attachment A_Individual_Family_Encounter_Form

Individual/Family Crisis Counseling Servies Encounter Log

OMB: 0930-0270

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Shape1 Shape2

OMB NO 0930-0270

Expiration Date xx/xx/xxxx



PROJECT #

Individual/Family Crisis Counseling Services Encounter Log

Shape3 Shape4

Shape5 Shape6 Provider Name Provider Number

Shape7 Shape8 Shape9 Date of Service (mm/dd/yyyy) County of Service

1st Employee # 2nd Employee # Zip Code of Service



VISIT TYPE (please check the appropriate box)




Number of participants in this encounter (either Individual OR Family or Household)



Shape10 Individual = 1



Shape14 Shape15 Shape11 Shape12 Shape13 Family or Household (2 or more individuals) = 2 3 4 5 6 or more





VISIT NUMBER

Shape16

First visit

Shape17

Second visit

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Third visit

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Fourth visit

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Fifth visit or later


DURATION

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15–29 minutes

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30–44 minutes

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45–59 minutes

Shape24

60 minutes or more












DEMOGRAPHIC INFORMATION


Number of MALES per age category in this encounter (indicate # in box)


Shape25

preschool (0–5 years)

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child (6–11 years)

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adolescent (12–17 years)

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adult (18–39 years)

Shape29

adult (40–64 years)

Shape30

older adult (65 years or older)


Number of FEMALES per age category in this encounter (indicate # in box)


Shape31

preschool (0–5 years)

Shape32

child (6–11 years)

Shape33

adolescent (12–17 years)

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adult (18–39 years)

Shape35

Shape36 adult (40–64 years)


older adult (65 years or older)
















Ethnicity (for individual encounter, select only one; for family encounter, select all that apply)

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Hispanic or Latino

Shape38

Not Hispanic or Latino



Race of participant(s) in this encounter (select all that apply)

Shape39


American Indian/Alaska Native

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Asian

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Black or African American

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Native Hawaiian/Pacific Islander

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White








Primary language spoken during encounter (select one)

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English

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Spanish

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Shape47 Other (specify in box) >>>>




If any of the participants has a disability, or other access or functional need, indicate the type (select all that apply).

Shape48

Physical (mobility, visual, hearing, medical, etc.)

Shape49 Shape50 Intellectual/Cognitive (learning disability, mental retardation, etc.)

Mental Health/Substance Abuse (psychiatric, substance dependence, etc.)



LOCATION OF SERVICE (select one)

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school or child care (all ages through college)

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temporary home (including friend or family homes, group homes, shelters, apartments, trailers, and other dwellings)

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community center (e.g., recreation club)

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IF HOME: PLEASE CHECK THIS BOX IF ANY

CHILDREN < AGE 18 LIVE IN THIS HOME.

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provider site/mental health agency (agency involved with Crisis Counseling Assistance and Training Program [CCP])

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permanent home

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workplace (workplace of the disaster survivor and/or first responder)

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IF HOME: PLEASE CHECK THIS BOX IF ANY CHILDREN < AGE 18 LIVE IN THIS HOME.

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disaster recovery center (e.g., Federal Emergency Management Agency [FEMA], American Red Cross)

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phone counseling (15 minutes or longer)

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place of worship (e.g., church, synagogue, mosque)

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If HOTLINE, HELPLINE, or CRISIS LINE, please check here.

Shape63

retail (e.g., restaurant, mall, shopping center, store)

Shape64

medical center (e.g., doctor, dentist, hospital, mental health or substance abuse specialty center)

Shape65

public place/event (e.g., street, sidewalk, town square, fair, festival, sports)

Shape66

Shape67 other (specify in box)>



RISK CATEGORIES (select all that apply)

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family missing/dead

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life was threatened (self or household member)

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displaced from home 1 week or more

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friend missing/dead

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witnessed death/injury (self or household member)

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sheltered in place or sought shelter due to immediate threat of danger

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pet missing/dead

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assisted with rescue/recovery (self or household member)

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past substance use/mental health problem

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home damage

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injured or physically harmed (self or household member)

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preexisting physical disability

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vehicle or major property loss

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had to change schools (for children or youth)

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past trauma

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other financial loss

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evacuated quickly with no time to prepare



Shape85

disaster unemployed (self or household member)

Shape86

prolonged separation from family



EVENT REACTIONS (select all that apply)

Shape87 Shape88 Shape89 Shape90 Shape92 Shape91 Please indicate the total # of participants experiencing event reactions. 1 2 3 4 5 6 or more

BEHAVIORAL

EMOTIONAL

PHYSICAL

COGNITIVE

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extreme change in activity level

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sadness, tearful

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headaches

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distressing dreams, nightmares

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excessive drug or alcohol use

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irritable, angry

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stomach problems

Shape100

intrusive thoughts, images

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isolation/withdrawal

Shape102

anxious, fearful

Shape103

difficulty falling or staying asleep

Shape104

difficulty concentrating

Shape105

on guard/hypervigilant

Shape106

despair, hopeless

Shape107

eating problems

Shape108

difficulty remembering things

Shape109

agitated/jittery/shaky

Shape110

feelings of guilt/shame

Shape111

worsening of health problems

Shape112

difficulty making decisions

Shape113

violent or dangerous behavior

Shape114

numb, disconnected

Shape115

fatigue, exhaustion

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preoccupied with death/destruction

Shape117

acts younger than age (children or youth)


Shape118





COPING WELL: NONE OF THE ABOVE APPLY

(If there are no participants experiencing the above event reactions, please check this box.)


FOCUS OF ENCOUNTER (select all that apply)



INFORMATION/EDUCATION ABOUT:



TIPS FOR:



HEALTHY CONNECTIONS


Shape119

reactions to disaster

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reducing negative thoughts


Shape121

building social network(s)

Shape122 other (specify in box)

Shape123

Shape124 community resources


managing physical and emotional reactions (e.g., breathing techniques)

Shape125

participating in community action


Shape126

this crisis counseling program

Shape127


doing positive things






Shape128


problem solving





MATERIALS PROVIDED FOR THIS ENCOUNTER


Were flyers, brochures, handouts, or other materials provided to this/these participant(s)?

Shape129

YES

Shape130

NO


REFERRAL (select all that were communicated)

Shape131

crisis counseling program services (e.g., group counseling, referral to team leader, followup visit)

Shape132

community services (e.g., FEMA, loans, housing, employment, social services)

Shape133

mental health services (e.g., professional, longer-term counseling, treatment, behavioral, or psychiatric services)

Shape134

resources for those with disabilities, or other access or functional needs

Shape135

substance abuse services (e.g., professional, behavioral, or medical treatment or self-help groups, such as Alcoholics Anonymous or Narcotics Anonymous)

Shape136

Shape137 other (specify in box)


Shape138 NO REFERRAL PROVIDED

Shape141 Shape139 Shape140

Reviewer Name Signature Date of Review



INSTRUCTIONS:

INDIVIDUAL/FAMILY CRISIS COUNSELING SERVICES ENCOUNTER LOG


When to Use This Form:

Complete this form immediately after the individual or family/household crisis counseling service is provided.

  1. Complete this form for each individual or family/household that receives crisis counseling services of 15 minutes or more.

  2. An individual or family/household crisis counseling encounter is defined as a contact where the discussion goes beyond education and assists understanding of current situations and reactions, involves review of options, or addresses emotional support or referral needs.

  3. This form is not intended to be used as a survey. Do not ask the individual for any of the information on this form. Complete all items on the form based on your best observations and information you received during the encounter.


PROJECT #—FEMA disaster declaration number, e.g., DR-XXXX-State.

PROVIDER NAME—The name of the program/agency.

PROVIDER NUMBER—The unique number under which your program/agency is providing services.

DATE OF SERVICE—The date of the encounter in the format mm/dd/yyyy, e.g., 01/01/2012.

COUNTY OF SERVICE—The county where the service occurred.

1st EMPLOYEE #—YOUR employee number (must be numeric and no more than 6 digits.)

2nd EMPLOYEE #—Employee number of your teammate during this encounter (must be numeric and no more than 6 digits.)

ZIP CODE OF SERVICE—The zip code of the location where the service occurred.


VISIT TYPE—Was this encounter with one person (individual) or with two or more individuals living as a family or household (family or household)?


VISIT NUMBER—Based on your conversation, is this the first, second, third, fourth, fifth, or later visit for this person, family, or

household to your program? All visits did not have to be with you. SELECT ONLY ONE.


DURATION—How long did your encounter last? SELECT ONLY ONE. If the encounter was under 15 minutes, record it on the

Weekly Tally Sheet.


DEMOGRAPHIC INFORMATION—For each variable.

NUMBER OF MALES IN THIS ENCOUNTER—Please indicate the number of males for each age category that

participated in this encounter. (You should record numbers into the boxes instead of checkmarks.)

NUMBER OF FEMALES IN THIS ENCOUNTER—Please indicate the number of females for each age category that

participated in this encounter. (You should record numbers into the boxes instead of checkmarks.)

ETHNICITY—Based on your observations and your conversation, do any of the participants self-identify as Hispanic/Latino?

RACE—Based on your observations and your conversation with the participants, what race do you think participant(s)

would identify as being? SELECT ALL THAT APPLY. If participant(s) are of more than one race, you should indicate all races that you believe to be represented. For a family encounter, if more than one race is represented, you should indicate all races that you believe to be represented.

PRIMARY LANGUAGE SPOKEN DURING ENCOUNTER(S)—Which language did you actually and primarily use to speak with this individual during the encounter? This may be different than the preferred language. If “OTHER” (not English or Spanish, may include sign language), fill in the other language that the person used. (SELECT ONLY ONE.)

PERSONS WITH DISABILITIES OR OTHER ACCESS OR FUNCTIONAL NEED(S)—Based on your observations and your conversation with the participants, does anyone have a physical, intellectual/cognitive, or mental health/substance abuse disability? SELECT ALL THAT APPLY.

  • Physical: includes disorders that impair mobility, seeing, hearing, as well as medical conditions, such as diabetes, lupus, Parkinson’s, AIDS, or multiple sclerosis (MS).

  • Intellectual/Cognitive: includes learning disabilities, birth defects, neurological disorders, developmental disabilities, or traumatic brain injuries (e.g., Down syndrome, mental retardation).

  • Mental Health/Substance Abuse: includes psychiatric disorders, such as bipolar disorder, depression, posttraumatic stress disorder (PTSD), schizophrenia, and substance dependence.

LOCATION OF SERVICE—Where did this encounter take place? SELECT ONLY ONE.


RISK CATEGORIES—These are factors that participants may have experienced or may have present in their lives that could increase

their need for services. MORE THAN ONE CATEGORY MAY APPLY. SELECT ALL CATEGORIES THAT APPLY.


EVENT REACTIONS—Do not use this as a checklist during the encounter. Complete this based on your observations and the conversation AFTER the service is complete. SELECT ALL THAT APPLY. If the participants have no observable or reported problems, check “coping well: none of the above apply.”


FOCUS OF INDIVIDUAL, FAMILY, OR HOUSEHOLD ENCOUNTER—What is the focus of the encounter? SELECT ALL THAT APPLY. If the focus is different from the categories listed, please select “OTHER,” and fill in the blank with the primary purpose.


MATERIALS PROVIDED IN THIS ENCOUNTER—Did you leave any materials with the participant, family, or household? This refers to printed materials such as a brochure, flyers, tip sheets, or other printed information. SELECT ONLY ONE.


REFERRAL—Based on your conversations, you may have referred the participants for other services. In the REFERRAL box, select all of the types of services to which you referred participants. If you made a referral to a service not listed, please check the box labeled “other” and write in the specific type of referral.


REVIEWER—Team lead or direct supervisor to review completed form for accuracy and then sign and date (date of review).


Please submit the completed form to the designated person in your agency who will review the form.

Thank you for taking the time to complete this form accurately and fully!


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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0270. Public reporting burden for this collection of information is estimated to average 8 minutes per encounter, 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, MD 20857.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCourtney Dawson
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File Created2021-01-24

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