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

OMB NO. 0930-0270

Project #

Expiration Date XX/XX/XXXX

Individual/Family Crisis Counseling Services Encounter Log
Provider #

Provider Name
Date of Service
(mm/dd/yyyy)

County or Parish of Service
2nd Employee #

1st 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
VISIT NUMBER
DURATION

Family or Household (2 or more individuals) = 2
First visit
15–29 minutes

Second visit
30–44 minutes

Third visit
45–59 minutes

3

4

5

6 or more

Fourth visit
60 minutes or more

Fifth visit or later

adult
(30–64 years)

older adult
(65 years or older)

adult
(30–64 years)

older adult
(65 years or older)

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)

young adult
(18–29 years)

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

child
(6–11 years)

adolescent
(12–17 years)

young adult
(18–29 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)

young adult
(18–29 years)

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

adult
(30–64 years)

older adult
(65 years or older)

Black or African American
Hispanic or Latin

Did any of the participants move from another country to the United States in the past 5
Yes
No
years? (select one)
Primary language spoken during encounter Which language did you actually and primarily use to speak with this individual during the

encounter? This may be different from the preferred language. If “OTHER” (not English or Spanish), fill in the other language that the person used
(may include sign language). SELECT ONLY ONE.

English

Spanish

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)
•

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

Intellectual/cognitive (learning
disability, developmental delay, etc.)

Mental health/substance use (psychiatric,
substance use disorder, 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
the 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 site (e.g., restaurant, mall, shopping center, store)
public place/event (e.g., street, sidewalk, town square,
fair, festival, sports)

temporary home (including home of friend or family, group
homes, shelters, apartments, trailers, and other dwellings)
IF TEMPORARY HOME: PLEASE CHECK THIS BOX IF ANY
CHILDREN UNDER AGE 18 LIVE IN THIS HOME.
permanent home
IF PERMANENT HOME: PLEASE CHECK THIS BOX IF ANY
CHILDREN UNDER AGE 18 LIVE IN THIS HOME.
phone counseling (outbound calls to participants lasting 15 minutes or longer)
hotline, helpline, or crisis line (inbound calls from participants lasting 15 minutes
or longer)
medical center (e.g., doctor, dentist, hospital, mental health or substance use
disorder treatment office)
virtual (e.g., text line, online chat service, Zoom)
other (specify in box)

RISK CATEGORIES (select all that apply)
life was threatened (self or household member)
witnessed death/injury (self or household member)
assisted with rescue/recovery (self or household
member)
changed schools or learning format (e.g., virtual)
prolonged separation from social network/family,
physical isolation, or social distancing
evacuated quickly with no time to prepare
displaced from home 1 week or more
sheltered in place or sought shelter due to
immediate threat of danger

family missing/dead
friend missing/dead
pet missing/dead
home damaged or destroyed
vehicle or major property loss
other financial loss
disaster un- or
underemployment (self or
household member)
illness, injury, or physical harm
(self or household member)

past substance use/mental health
problem
preexisting physical disability
past trauma
disaster-caused food insecurity
reduced or no access to reliable
information/communication
reduced or no access to reliable
transportation

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

EMOTIONAL

extreme change in activity
level
excessive drug or alcohol use
isolation/withdrawal
on guard/hypervigilant
agitated/jittery/shaky
violent or dangerous behavior
acts younger than age
(children or youth)

•

1

•

2

PHYSICAL

•

3

•

4

•

5

6 or more

COGNITIVE

sadness, tearful

headaches

irritable, angry
anxious, fearful
despair, hopeless
feelings of guilt/shame
numb, disconnected

stomach/digestive problems
difficulty falling or staying asleep
eating problems
worsening of health problems
fatigue, exhaustion

distressing dreams,
nightmares
intrusive thoughts, images
difficulty concentrating
difficulty remembering things
difficulty making decisions
preoccupied with
death/destruction

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:
reducing negative thoughts

HEALTHY CONNECTIONS:

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

doing positive things

mutual support/building social networks

participating in community action

problem solving

other (specify in box)

MATERIALS PROVIDED IN THIS ENCOUNTER (select only one)
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, referral 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 use 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

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., State-XXXX.
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., 01/01/2021.
COUNTY OF SERVICE—The county or parish where the service occurred.
1st EMPLOYEE #—YOUR employee number issued by ODCES (must be numeric and no more than 6 digits).
2nd EMPLOYEE #—Employee number issued by ODCES for 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)? SELECT ONLY ONE.
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, 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 in 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 in 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 in 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 races/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.
MOVED TO THE UNITED STATES IN THE PAST 5 YEARS—Indicate if any participant moved to the United States in the past
5 years from any country and for any reason. SELECT ONLY ONE.
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 from the preferred language. If “OTHER” (not English or Spanish, and
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 use 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 disease, acquired immunodeficiency syndrome (AIDS), and multiple sclerosis (MS).
•
Intellectual/cognitive: includes a learning disability, birth defects, neurological disorders, developmental disabilities
(e.g., Down syndrome), and traumatic brain injuries.
•
Mental health/substance use: includes psychiatric disorders, such as bipolar disorder, major depressive disorder,
posttraumatic stress disorder (PTSD), schizophrenia, and substance use disorders.
LOCATION OF SERVICE—Where did the encounter occur? SELECT ONLY ONE.
RISK CATEGORIES—These are the 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 memory of 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 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 materials
such as brochures, flyers, tip sheets, schedules of in-person/virtual groups, or other 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.
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 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, 5600
Fishers Lane, Room 15E57A, Rockville, MD 20857.