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Template Bi-Weekly Statistical and Narrative Report
Report #
#1 Consultations (Stakeholder interactions other than the SM themselves) [Early intervention]
| Total New Consultations: |
| Only count consultations related to a new issue. All follow up consultations should be counted as follow up. |
| Total Follow Up Consultations: |
| Count the number of follow up consultations you made for the reporting period. |
Total Number of Consultations:
| Enter areas of consultation for combined consults listed on lines 10 and 13. The sum of the numbers in rows 19 - 21 should equal the value on line 16. | | | | | |
| Affiliated Provider (VA, Vet Center, MTF) | 0 | Helping Agency/Program | 0 | Legal/IG | 0 |
| Chaplain | 0 | Law Enforcement | 0 | Military Medical (include case managers) | 0 |
| Friend/Family | 0 | Leadership | 0 | Wingman/Battle Buddy | 0 |
Does the sum of rows 19-21 match the value in row 16? Yes
#2 Types of Contact
| Outreach Contact: | 0 |
| Contacts made with community partners to expand resources available for NG SMs. | |
| Information and Referrals (Green) [Prevention]: | 0 |
| These are program-oriented interactions with SMs where a formal case is not open. The discussion is related to non-clinical issues such as provision of information related to everyday life issues but does not involve a referral to a treatment provider. In these contacts, there are no clinically significant issues. | |
| New Early Intervention Cases (YELLOW): | 0 |
| Active Early Intervention Cases (opened in previous month): | 0 |
| DIRECTIONS: | |
For new cases, only count SMs who are clients for whom you opened a new case in this reporting period. In the block for previously opened cases, include cases for which you provided services this month that had been reported as new in a previous month. All Early Intervention cases in which you were involved this month should be reflected in one of these two cells. Only count an Early Intervention case in one of these two cells. In Early Intervention cases, SMs often present with transient life sessions, which can be addressed in 1-3 sessions (May be up to 6 with Regional Lead approval) utilizing solutions-focused problem solving support. SMs may initially present in a Yellow status, but be headed toward an Orange status. SM's may need up to 3 sessions of a Bio Psychosocial assessment to determine if they require a community referral. The numbers in line 74 should reflect the total number of new and previously opened Early Intervention CASES with which you were involved in this reporting period. The number in lines 37 should reflect the total number of CONTACTS made with clients with Early Intervention Cases (include new and previously opened cases. The number in line 39 reflects the number of contacts you made on behalf of Early Intervention clients (do not count the contacts made directly with clients since that is reported in line 37).
| Early Case Follow up Contacts (Client): | 0 |
| Count the total number of follow up contacts you made this reporting period | |
| Early Intervention Case Management Contacts (Counselor): | 0 |
| Count the total number of case management contacts you made this reporting period. | |
| New Intervention/Crisis Reponses Cases (Orange-Red): | 0 |
| Active CI/CR Cases opened in previous month: | 0 |
| DIRECTIONS: | |
In the first block, only count SMs who are clients for whom you opened a new case in this reporting period. In the second block, record the number of Intervention/Crisis Response cases which were opened in a previous month for which you provided services in this reporting period. Only count a case in one of the two cells. SMs may present as an emergent case with clinical presentation and may have mild to moderate SI/HI, serious mental health diagnosis and/or reoccurring DTWs. Once a SM is entered as a new case, regardless of a change in status (color), they are not to be reentered again when that status change occurs.
| Clinical Case Contacts (Client): | 0 |
| Count the total number of contacts with intervention/crisis response clients you made during this reporting period. | |
| Clinical Case Management Contacts (Counselor): | 0 |
| Count the total number of case management contacts you made this reporting period. | |
Number of New Early Intervention, Intervention/Crisis Response Cases (lines 33 and 42): 0
#3 Suicide Risk Reporting
| Suicide mitigation 1: | 0 |
| SM has a plan, the means and intent to carry out suicide unless someone intervenes | |
| Suicide mitigation 2: | 0 |
| Anything that falls short of mitigation 1 but still falls on the self-directed violence suicide continuum | |
| #4 Duty to Warn/Duty to Protect: | |
| Child Abuse: | 0 |
| Criminal: | 0 |
| Elder Abuse: | 0 |
| Homicide: | 0 |
| Substance Abuse: | 0 |
| Total | 0 |
Total New High Risk cases (Lines 57, 60, 70) 0
| #5 Total New Crisis Intervention/Clinical Cases | |
| This section captures data on the primary category which your NEW crisis intervention/crisis response cases fall into. Select the category which best depicts the reason for your intervention with a SM. The sum of this column should equal the number of new intervention/crisis response cases reported in line 52. | |
| New Intervention/Crisis Response Categories: | |
| Alcohol and/or other drug use | 0 |
| Child, elder, vulnerable person abuse/neglect | 0 |
| Confirmed PTSD/TBI cases | 0 |
| Emergency or urgent referral to a mental health provider | 0 |
| Homicidal Risk | 0 |
| Partner abuse - Victim | 0 |
| Partner Abuse - Aggressor | 0 |
| Suicidal Risk | 0 |
| Threats or actual Acts of Violence towards others | 0 |
| Other | 0 |
| TOTAL | 0 |
| Does this value match the number in Line 52? | Yes |
| Formerly closed cases that were reactivated: | 0 |
| This should include cases that were closed at least 6 months before. | |
| #6 Demographics |
| For these demographic fields below, only report on new Early Intervention, Intervention/Crisis Response cases (lines 33 and 42). The total number should match the value in line 52. |
| Employment Status | | Referred By | | Age | |
| Full-Time: | 0 | Self: | 0 | 18-29: | 0 |
| Traditional: | 0 | Command: | 0 | 30-49: | 0 |
| Other: | | Other: | 0 | 50+ | |
| Total | 0 | Total | 0 | Total | 0 |
| Total Matches Line 52? | Yes | Total Matches Line 52? | Yes | Total Matches Line 52? | Yes |
| Martial Status | | Ethnicity | | Rank | |
| Married: | 0 | African American: | | CIV: | |
| Partnered: | | Asian: | | E1-5: | |
| Single: | 0 | Caucasian: | 0 | E6-9: | |
| Widowed: | | Hispanic/Latino: | 0 | O1-4: | |
| Separated: | 0 | Pacific Islander: | | O5+: | |
| Divorced: | 0 | Other: | | CW1-5: | |
| Total | 0 | Total | 0 | Total | 0 |
| Total Matches Line 52? | Yes | Total Matches Line 52? | Yes | Total Matches Line 52? | Yes |
| Employment Status | |
| Male: | 0 |
| Female: | 0 |
| Total | 0 |
| Total Matches Line 52? | Yes |
| #7 Presenting Problem (For cases reflected in lines 33 and 42; Early Intervention, Intervention/Crisis Response cases) |
| Record ALL problem issues presented by clients with a case record (But only record each problem once). Specifically, all (both Early Intervention and Crisis Intervention/Response) Case Follow Up Contacts and All Case Management Contacts with existing clients do not need the same presenting problems counted again, but do count different presenting problems that may show up in Follow Up and Case Management activities. |
| Abuse-Aggressor: | 0 | Homicide of Other: | 0 |
| Abuse-Victim: | 0 | Legal: | 0 |
| Alcohol: | 0 | Psychiatric: | 0 |
| Anger: | 0 | PTSD-Diagnosed: | 0 |
| Anxiety: | 0 | PTSD-Impression: | 0 |
| Assault Victim: | 0 | School: | 0 |
| Deployment: | 0 | Sleep: | 0 |
| Depression: | 0 | Stress Management: | 0 |
| Drugs: | 0 | Suicidal Ideation: | 0 |
| Family/Marital: | 0 | Suicide of Other: | 0 |
| Financial: | 0 | TBI: | 0 |
| Grief: | 0 | Violence: | 0 |
| Health: | 0 | Work Related: | 0 |
| Homicidal Ideation: | 0 | | |
| #8 Referrals | |
| Total number of Individuals Referred: | 0 |
| Referred to: | | | |
| Caregiver Support: | 0 | Referral Counselor: | 0 |
| Chaplain/Clergy/Spiritual Services: | 0 | Social/Recreational: | 0 |
| ESGR/Employment Support: | 0 | Substance Abuse-Inpatient: | 0 |
| Financial Support: | 0 | Substance Abuse- Day Treatment: | 0 |
| Health Promotion/Wellness: | 0 | Substance Abuse-Outpatient: | 0 |
| Legal: | 0 | Support Staff (A&FRPM,FAC,SARC,SPPM/TAA): | 0 |
| MFLC: | 0 | VA Medical Center: | 0 |
| Military Treatment Facility: | 0 | Vet Center: | 0 |
| MOS: | 0 | Web Support, Book, or Reading Materials: | 0 |
#9 Timeliness of Appointments
| Criteria | Routine Cases | Urgent Cases | Total |
| Number of appointments made within policy guidelines | 0 | 0 | 0 |
| Number of Appointments made outside of policy guidelines | 0 | 0 | 0 |
| Total | 0 | 0 | 0 |
#10 Training and Attendance
Group Education/Psychoeducation (Prevention)
| Pre-deployment Events: | 0 |
| The number of pre-deployment events you attended in this reporting period (e.g.: non-Yellow Ribbon event, SRP, screening, PHAs). | |
| Post-deployment Events: | 0 |
| The number of post-deployment events (demobilization) events you attended in this reporting period (e.g. non-Yellow Ribbon, PDHRA) | |
Yellow Ribbon Events: 0
| PHC Program Briefings Conducted: | 0 | Total number of SMs in attendance: | 0 |
| A PHC Program Briefing is a short discussion on the PHC's role, how to reach them and program mission; "briefings do not include any life skills education" | | | |
| Psycho-education (Prevention) | | | |
| Trainings Conducted: | 0 | Total number of SMs in attendance: | 0 |
| Psycho-education events refers to sessions where the PHC is teaching and/or discussing a specific skill or behavior such as stress management, resiliency, sleep hygiene, time management, relational dynamics. | | | |
We will assume for each psycho-educational session, the PHC will include during the course of their teaching a short discussion on who they are, the program mission and how to reach them.
| Briefing/Psycho-Educational Topics: | |
| PTSD: | 0 |
| TBI: | 0 |
| Depression: | 0 |
| Suicide: | 0 |
| Family: | 0 |
| Deployment Related Issues: | 0 |
| Alcohol/Drugs | 0 |
| Psychological Health Program: | 0 |
| Other: | 0 |
| #11 Postvention (Traumatic Event Management/Traumatic Stress Response) Activities |
| In this section , include all activities for which Traumatic Event Management or Trauma Response Services were needed. Please round to the nearest whole hour. |
| Category | Time Spent |
| Suicide | 0 |
| SM Death(not suicide) | 0 |
| Natural Disaster | 0 |
| Accident (e.g., plane crash, building collapse) | 0 |
| Bombings, shootings, etc. | 0 |
| Other | 0 |
| Total | 0 |
