Individual/Family Crisis Counseling Servies Encounter Log

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Document Name Document Type
Form Individual/Family Individual/Family Crisis Counseling Servies Encounter Log Form
Individual/Family Individual/Family Encounter Log Attachment A-IndividualFamilyEncounterForm-Rev.pdf Form
Group Encounter Lo Group Encounter Log Attachment B-GroupEncounterLog-Rev.pdf Form
Weekly Tally Sheet Weekly Talkly Sheet Attachment C-WeeklyTallySheet-Rev.pdf Form
Adult Assessment a Adult Assessment and Referral Tool Attachment D-AdultAssessmentandReferralTool-Rev.pdf Form
Child/YOuth Assess Child/YOuth Assessment and Referral Tool Attachment E-ChildYouthAssessmentandReferralTool-Rev.pdf Form
Service Provider F Service Provider Feedback Form Attachment G-ServiceProviderFeedbackForm-Rev.pdf Form

Information Collection (IC) Details

IC Title:	Individual/Family Crisis Counseling Servies Encounter Log	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Individual/Family Encounter Log	Individual/Family Encounter Log	Attachment A-IndividualFamilyEncounterForm-Rev.pdf	Yes	Yes	Fillable Fileable Signable
Form	Group Encounter Log	Group Encounter Log	Attachment B-GroupEncounterLog-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Weekly Tally Sheet	Weekly Talkly Sheet	Attachment C-WeeklyTallySheet-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Adult Assessment and Referral Tool	Adult Assessment and Referral Tool	Attachment D-AdultAssessmentandReferralTool-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Child/YOuth Assessment and Referral Tool	Child/YOuth Assessment and Referral Tool	Attachment E-ChildYouthAssessmentandReferralTool-Rev.pdf	Yes	Yes	Fillable Fileable
Form	Service Provider Feedback Form	Service Provider Feedback Form	Attachment G-ServiceProviderFeedbackForm-Rev.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	117,600	117,600
Annual IC Time Burden (Hours)	9,408	9,408
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.