Form Individual/Family Individual/Family Individual/Family Encounter Log

OMB NO. 0930-0270

Project #

Expiration Date xx/xx/xxxx

Individual/Family Crisis Counseling Services Encounter Log
Provider Name

Provider #

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)
Individual = 1

Family or Household (2 or more individuals) = 2

3

4

5

VISIT NUMBER

First Visit

Second visit

Third visit

Fourth visit

DURATION

15-29 minutes

30-44 minutes

45-59 minutes

60 minutes or more

6 or more
Fifth visit or later

DEMOGRAPHIC INFORMATION
Number of MALES per age category in this encounter (indicate # in box)
preschool
(0-5 years)

child
(6-11 years)

adolescent
(12-17 years)

adult
(18-39 years)

adult
(40-64 years)

older adult
(65 years or older)

adult
(40-64 years)

older adult
(65 years or older)

Number of FEMALES per age category in this encounter (indicate # in box)
preschool
(0-5 years)

child
(6-11 years)

adolescent
(12-17 years)

adult
(18-39 years)

Number of TRANSGENDER individuals per age category in this encounter (indicate # in box)
preschool
(0-5 years)

child
(6-11 years)

adolescent
(12-17 years)

adult
(18-39 years)

adult
(40-64 years)

older adult
(65 years or older)

Race/ethnicity of participants in this encounter (select all that apply)
American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian/Other Pacific Islander

White

Hispanic or Latino

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, developmental delay, etc.)

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

LOCATION OF SERVICE (select one)
school and child care (all ages through college)
community center (e.g., recreation club)
provider site/mental health agency (agency involved with
Crisis Counseling Assistance and Training Program [CCP])
workplace (workplace of the disaster survivor and/or first
responder)
disaster recovery center (e.g., Federal Emergency
Management Agency [FEMA], American Red Cross)
place of worship (e.g., church, synagogue, mosque)
retail (e.g., restaurant, mall, shopping center, store)
public place/event (e.g., street, sidewalk, town square, fair,
festival, sports)

temporary home (including friend or family homes, group
homes, shelters, apartments, trailers, and other dwellings)
IF HOME: PLEASE CHECK THIS BOX IF ANY
CHILDREN < AGE 18 LIVE IN THIS HOME.
permanent home
IF HOME: PLEASE CHECK THIS BOX IF ANY
CHILDREN < AGE 18 LIVE IN THIS HOME.
phone counseling (15 minutes or longer)
If HOTLINE, HELPLINE, or CRISIS LINE, please check here.
medical center (e.g., doctor, dentist, hospital, mental health, or
substance abuse specialty center)
other (specify in box)

RISK CATEGORIES (select all that apply)
family missing/dead

injured or physically harmed (self or household
member)

evacuated quickly with no time to prepare

friend missing/dead

life was threatened (self or household member)

displaced from home 1 week or more

pet missing/dead

witnessed death/injury (self or household member)

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

home damaged or destroyed

assisted with rescue/recovery (self or household
member)

past substance use/mental health
problem

vehicle or major property loss

had to change schools

preexisting physical disability

other financial loss

prolonged separation from family

past trauma

disaster unemployed (self or household member)

EVENT REACTIONS (select all that apply)
Please indicate the total # of participants experiencing event reactions.
BEHAVIORAL

EMOTIONAL

1

2

3

4

PHYSICAL

5

6 or more

COGNITIVE

extreme change in activity
level

sadness, tearful

headaches

distressing dreams,
nightmares

excessive drug or alcohol use

irritable, angry

stomach problems

intrusive thoughts, images

isolation/withdrawal

anxious, fearful

difficulty falling or staying asleep

difficulty concentrating

on guard/hypervigilant

despair, hopeless

eating problems

difficulty remembering
things

agitated/jittery/shaky

feelings of guilt/shame

worsening of health problems

difficutly making decisions

violent or dangerous behavior

numb, disconnected

fatique, exhaustion

preoccupied with
death/destruction

acts younger than age
(children or youth)

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:

reactions to disaster

community resources

this crisis counseling program

TIPS FOR:
reducting negative thoughts
HEALTHY CONNECTIONS:

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

doing positive things

problem solving

mutual support/building social networks

participating in community action

other (specify in box)

FOCUS OF GROUP SESSION (select all that apply)
Were flyers, brochures, handouts, or other materials provided to this/these participant(s)?

YES

NO

REFERRAL (select all that were communicated)
crisis counseling program services (e.g., group counseling, referall to team
leader, follow-up visit)

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

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

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

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

other (specify in box)

NO REFERRAL PROVIDED
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 understand 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-XXX-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/yyy, 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 lond did your encounter last? SELECT ONLY ONE. If the encounter was under 15 minutes, use 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.)
NUMBER OF TRANSGENDER INDIVIDUALS IN THIS ENCOUNTER—Please indicate the number of transgender individuals for each
age category that participated in this encounter. (You should record numbers into the boxes instead of checkmarks.)
RACE/ETHNICITY—Based on your observations and your conversation with the participants, what race/ethnicity do you think the
participant(s) would identify as being? SELECT ALL THAT APPLY. If participant(s) are of more than one race/ethnicity,
you should indicate all race/ethnicities that you believe to be represented. For a family encounter, if more than one race/
ethnicity is represented, you should indicate all races/ethnicities 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, 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 defects, neurological disorders, developmental disabilites, or
traumatic brain injuries, (e.g., Down syndrome).
•
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 the encounter occur? SELECT ONLY ONE.
RISK CATEGORIES—These are the factos 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 coversation 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 fillin 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!
Paperwork Reduction Act Statement This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA)
with program monitoring of FEMA’s Crisis Counseling Assistance and Training Program. Crisis counselors are required to complete this form following the delivery
of crisis counseling services to disaster survivors (44 CFR 206.171 [F][3]). Information collected through this form will be used at an aggregate level to determine
the reach, consistency, and quality of the Crisis Counseling Assistance and Training Program. Under the Privacy Act of 1974, any personally identifying
information obtained will be kept private to the extent of the law. 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 0930-0270. 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, 5600 Fishers Ln, Room 15E57B, Rockville,
MD 20857.