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.
