Form Group_Encounter_Lo Group_Encounter_Log

Project # Group Encounter Log OMB NO. 0930-0270

Expiration Date xx/xx/xxxx

Provider Name Provider Number

1^st Employee # Date of Service (mm/dd/yyyy)

2^nd Employee # County of Service Zip Code of Service

TYPE OF SERVICE (select one before completing this log)

GROUP COUNSELING PUBLIC EDUCATION

(a group meeting where participants did (a presentation or group meeting where YOU

most of the talking) did most of the talking)

CHARACTERISTICS of ENCOUNTER

LOCATION of SERVICE (select one)

school and child care (all ages through college)

home (temporary or permanent residence, including friend/family home; group homes, including houses, apartments, trailers, and other dwellings)

community center (e.g., recreation club)

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

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

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

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

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

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

other (specify in box) >

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

SESSION NUMBER (select one)

First session of group expected to meet once

First session of group expected to meet more than once

Second or greater session of ongoing group

NUMBER of PARTICIPANTS PLEASE ESTIMATE

Number under age 18

Number ages 18–64

Number age 65 and older

TOTAL

DURATION

15–29 minutes

30–44 minutes

45–59 minutes

60 minutes or more

GROUP IDENTITIES (select one)

Was the group composed ONLY or MOSTLY of any of the following:

Children or youth (under age 18)? CHECK, if yes.

Adult survivors (adults who were directly affected by the disaster)? CHECK, if yes.

Public safety workers and first responders (e.g., police, fire, emergency medical services, rescue)? CHECK, if yes.

Other recovery workers (e.g., health care, disaster relief, social services)? CHECK, if yes.

Was the group composed of a mixture of the above or none of the above (i.e., no clear group identity)? CHECK, if yes.

Ethnicity (select all that apply)

Hispanic or Latino

Not Hispanic or Latino

Race of participants in this encounter (select all that apply)
	American Indian/Alaska Native		Asian		Black or African American
	Native Hawaiian/Pacific Islander		White

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

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

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

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

FOCUS OF GROUP SESSION (select all that apply)

INFORMATION/EDUCATION ABOUT:		TIPS FOR:		HEALTHY CONNECTIONS
reactions to disaster		reducing negative thoughts		mutual support/ building social network(s)	other (specify in box)
community resources		managing physical and emotional reactions (e.g., breathing techniques)		participating in community action
this crisis counseling program		doing positive things
		problem solving

Were flyers, brochures, handouts, or other materials provided to participants? YES NO

Reviewer Name Signature Date of Review

INSTRUCTIONS:

GROUP ENCOUNTER LOG

When to Use This Form:

1. Complete this form immediately after the group encounter is provided. COMPLETE ONLY ONE FORM PER GROUP.

2. Group sessions involve at least two or more unrelated participants (excluding staff).

3. Do not use this form for families. Use the Individual/Family Crisis Counseling Services Encounter Log.

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 or agency is providing services.

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

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

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

COUNTY OF SERVICE—The county or parish where the group was held.

ZIP CODE OF SERVICE—The zip code of the location where you had the encounter.

GROUP CRISIS COUNSELING OR PUBLIC EDUCATION (SELECT ONE)

THE DATA ON THIS LOG CANNOT BE ENTERED OR COUNTED UNLESS YOU INDICATE TYPE OF SERVICE.

Group crisis counseling refers to services that help group members understand their current situation and reactions to the disaster, review or discuss their options, obtain emotional support or referral services, and/or develop or improve skills to cope with their current situation and reactions. In group counseling, participants do most of the talking.

Public education refers to services that provide general psycho-education to survivors on disaster services available and key concepts of disaster behavioral health. Common activities in this category include, but are not limited to, public speaking at community forums, in-service group meetings, and local government meetings. In public education, the crisis counselor does most of the talking.

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

SESSION NUMBER—Check the box beside the option that matches how many times the group has met and will meet. SELECT ONLY

ONE.

NUMBER OF PARTICIPANTS—Use all four boxes to report the number of participants (not including staff) and estimate their age distribution. For example, for seven participants including no adolescents, three adults under age 65, and four older adults, write in 0, 3, 4, 7.

DURATION—How long did your encounter last? SELECT ONLY ONE. If less than 15 minutes, use the Weekly Tally Sheet form.

GROUP IDENTITIES—This refers to the possible identities and/or roles that the group members might share as a whole. “Primarily” means that the majority of group members shared the listed characteristic. For example, a group focused on children that had a few adults present would meet the definition of a group composed “only or mostly” of children. Groups do not necessarily have an identity. If so, check the last box.

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 participants

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

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, or mental health/substance abuse disability? SELECT ALL THAT APPLY.

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

• Intellectual/Cognitive: includes a learning disability, birth defect, neurological disorder, developmental disability, or traumatic brain injury, e.g., Down syndrome and mental retardation.

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

FOCUS OF GROUP SESSION—What is the focus of this session/encounter? SELECT ALL THAT APPLY. If the focus for the group is different from the categories listed, please select “OTHER,” and fill in the blank with the primary purpose.

MATERIALS PROVIDED—Did you leave any materials with the participants? This refers to materials such as a crisis counseling program brochure, flyers, tip sheets, or other printed materials. SELECT ONLY ONE (yes/no).

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 and sign 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 4 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.