Magellan Military Family Life Counselor (MFLC) Activity Form

Transcription

1 Magellan Military Family Life Counselor (MFLC) Activity Form Instructions: Use only if smart phone and web application are unavailable. Complete a separate form for each activity. Complete only the sections applicable to the specific activity. Fully complete all applicable sections. SECTION A. GENERAL INFORMATION Counselor Name: Contact Date: Contractor Identification Number: Unique Numerical Identifier (UNI): Time Spent on Activity (Minutes) Location of Contact (select one) Armory Bowling alley (off installation) Bowling alley (on installation) Chapel Child and youth office/classroom Child Development Center Client Workplace (Duty Section) Commissary Community center (off installation) Community center (on installation) Deployment Processing Center Detention Center Exchange Family Center Offices Family Service Center / Family Assistance Center Fisher House Food Court/Dining Facility/Restaurant/Coffee Shop (off installation) Food Court/Dining Facility/Restaurant/Coffee Shop (on installation) Gym (off installation) Gym (on installation) Hangers Indoor/Outdoor Outreach Event Installation Housing Office Installation Medical/Hospital Primary Location: Secondary Location: On Installation Off Installation City: State: RAND (leave blank unless otherwise instructed): Installation Theater Installation Welcome Center Library (off installation) Library (on installation) Marriage Retreat or Couples Retreat MFLC Office Military Personnel Center Morning Formation Motor Pools MWR Facilities Office Building (on installation) On Demand Event Booth On Demand Event Hotel Common Area Passenger Terminal PFC Designated Office Playground/Park Recruiting Station Reserve Center Single Service Member Center Smoking Area Survivor Outreach Services Office Teen/Youth Center USO Wounded Warrior Facility Miscellaneous Location (on installation) Miscellaneous Location (off installation)

2 A1. ACTIVITY TYPE (select one) Rotational (complete Section A2) On Demand (complete Section A3) Surge CDC: Child Development Center Children/Youth Event (complete Section A4) Schools Caregiver Peer Support Forum Healthy Base Initiative United Services Organization JFSAP (until August 14) JFSAP Reserve (until August 14) A2. SECONDARY ACTIVITY TYPE (select one if applicable) AFRICOM: United States Africa Command CENTCOM: Central Command Embedded: Adult MFLCs Embedded Within Military Units General Support SOCOM: Special Operations Command USAREC: United States Army Recruiting Command USMC Recruiting: United States Marine Corp Recruiting Command A3. ON DEMAND SUPPORT Event Number: Military Component (select one): Air Force Active Duty Air Force Reserve Air National Guard Army Active Duty Army National Guard Army Reserve Joint Marine Corps Active Duty Marine Corps Reserve Navy Active Duty Navy Reserve Event Type (select one): Yellow Ribbon Deployment Support/Non-Yellow Ribbon (active duty) Family: Children/Youth Event (all camps included) Family: Family Event Event for Command Leaders: Wellness Fair Event for Command Leaders: SRP (Military Member Readiness Processing) Event for Command Leaders: Annual Training (ADT) Event for Command Leaders: Staff Professional Development Event for Command Leaders: Job and/or Career Fair Event for Command Leaders: Family Readiness Group Support Wounded Warrior/Casualty Natural Disaster Crisis Situation Drill Weekend Strong Bonds Retreat Caregivers Forum A4. CAMP TYPE (select one if applicable) Installation Based Summer Programs DODEA Summer School National Military Family Association Operation Purple Camps National Military Family Association Family Retreats Operation Military Kids Camps National Guard Camps Reserve Camps Camp name provided by program office

3 SECTION B. NON-MEDICAL FACE-TO-FACE COUNSELING Contact Type (choose one): Caregiver/Legal Guardian Child Couple Family Group Service Member Spouse Staff/Third Party Consultation Number of Attendees: How did the contact hear about the MFLC Program? (select one) Briefing/presentation Brochure/Flyer Casual Outreach Chaplain Civilian Service Provider Command Current or Prior MFLC Family Center/CYS: Child and Youth Services Staff FRG: Family Readiness Group Internet Medical Facility Military OneSource Service Recovery Care Coordinator Spouse/Family/Friend Is the issue related to deployment/reintegration? Is this a Duty to Warn situation? Continuing with MFLC? Eligibility? (complete Section E) Informed Consent? Service Member s/sponsor s Branch of Service: Air Force Army Marines Navy DoD Civilian Expeditionary Workforce/Civilian Employee Military Status of Individual/Sponsor: Active Duty (Current/Former) Guard Reserve Grade of Service Member/Sponsor: C1 C2 C3 C4 E1-E4 E5-E6 E7-E9 W1-W2 W3-W5 O1-O3 O4-O6 O7-O10 How old is the person this consultation is about? (select one) years or older How many prior contacts have you had with this contact? More than

4 B1. V-CODE (primary reason for consultation) No V-Code: Brief Contact (0-19 minutes if primary participant is 18 years of age or younger; 0-29 minutes if primary participant is 19 years of age or older) V61.20: Parent-Child Relational Problem V61.8: Sibling Relational Problem V61.8: Upbringing Away from Parents V61:8: High Expressed Emotion Level within Family V61.29: Child Affected by Parental Relationship Distress V61.10: Relationship Distress with Spouse or Intimate Partner V61.03: Disruption of Family by Separation or Divorce V62.82: Uncomplicated Bereavement V15.41: Personal History (Past History) of Physical, Psychological Abuse/Neglect V15.41: Personal History (Past History) of Spouse or Partner Violence, Physical, Sexual V15.42: Personal History (Past History) of Spouse or Partner Neglect, Psychological V62.3: Academic or Educational Problem V62.21: Problem Related to Current Military Deployment Status V62.29: Other Problem Related to Employment V60.0: Homelessness V60.1: Inadequate Housing V60.89: Discord with Neighbor, Lodger, or Landlord V60.6: Problem Related to Living in a Residential Institution V60.2: Lack of Adequate Food or Safe Drinking Water V60.2: Extreme Poverty V60.2: Low Income V60.2: Insufficient Social Insurance or Welfare Support V60.9: Unspecified Housing or Economic Problem V62.89: Phase of Life Problem, Victim of Crime V60.3: Problem Related to Living Alone V62.4: Acculturation Difficulty, Social Exclusion or Rejection, Target of (Perceived) Adverse Discrimination or Persecution V62.9: Unspecified Problem Related to Social Environment V62.9: Unspecified Problem Related to Unspecified Psychosocial Circumstances V62.5: Problems Related to Release from Prison or Other Legal Circumstances V65.40: Other Counseling or Consultation V62.89: Religious or Spiritual Problem V61.7: Problems Related to Unwanted Pregnancy V61.5: Problems Related to Multiparity V62.22: Exposure to Disaster, War, or Other Hostilities V62.22: Personal History of Military Deployment V15.49: Other Personal History of Psychological Trauma V15.59: Personal History of Self-Harm V15.89: Other Personal Risk Factors V69.9: Problem Related to Lifestyle V71.02: Child or Adolescent Antisocial Behavior V63.9: Unavailability or Inaccessibility of Health Care Facilities V63.8: Unavailability or Inaccessibility of Other Helping Agencies V78.00: Overweight or Obesity V62.89: Borderline Intellectual Functioning

5 SECTION C. INFORMATION AND REFERRAL (for both eligible and ineligible participants) Type: Information Only Referral Only Information and Referral Referred to (select all that apply): Medical Military Treatment Facility Local Community Hospital Public Health Department Veterans Hospital/Clinic Insurance TRICARE TRICARE Reserve Select Veterans Administration Private Insurance Child Care Child Care Aware of America (formerly NACCRA) Military Family Support Centers Marine Corps Community Service Center Air Force Family Service Center Fleet and Family Support Center State National Guard Family Support Program Domestic Violence Child Abuse Family Advocacy Program (FAP) Victim Advocate Parents Anonymous Domestic Violence Hotline (CPS) Department of Social Services Sexual Assault Sexual Assault Response Coordinator (SARC) RAINN (Rape Abuse and Incest Hotline) Victim Advocate Substance Abuse Substance Abuse Rehabilitation Program (SARP) Local Community Substance Abuse Rehabilitations Alcoholics Anonymous Relief Services Navy Marine Corps Relief Society Air Force Air Society Army Emergency Relief (AER) Coast Guard Mutual Assistance Red Cross United Service Organizations (USO) Women Information Children (WIC) Department of Social Services United Way Agencies Local Faith Based Organization Salvation Army/Goodwill Education Department of Defense Education (DoDEA) Wounded Warrior Programs Navy Safe Harbor Army Wounded Warrior Program (AW2) Marine Corps Wounded Warrior Regiment Air Force Wounded Warrior Program Command Services Personnel Office (PSD) Chaplain Casualty Assistance Officer YMCA/YWCA Office of Survivor Assistance Judge Advocate General (JAG) Morale Welfare and Recreation (MWR) Commissary (DeCA) Army, Navy, Air Force, Marine Corps Exchange Department of Defense Military OneSource Military OneSource Web Site Military OneSource Wounded Warrior Specialty Consultation Military Family Life Counselor MFLC

6 SECTION D. BRIEFING/PRESENTATION (only those approved by OSD) Type: Briefing Presentation Is this briefing/presentation related to deployment? If yes, select one: Pre-Deployment During Deployment Post-Deployment - Age group focused on in briefing/presentation: years or older SECTION E. PARTICIPANT NOT ELIGIBLE, OUT OF SCOPE, WARM HAND-OFF Type: Not eligible Out of scope Referral/warm hand-off Briefing/Presentation Category (select one): Anger Management Child and Youth Command Support Communication Compassion Fatigue Conflict Resolution Deployment Financial Grief/Loss Marital/Couples Parenting Program Briefing Return/Reunion Stress Management Number of Participants: Active Duty Reserve National Guard Command Support Civilian Total NOTE: If participants are Command Support, skip Age group focused on in briefing/presentation. Reason (explanation of Type choice) NOTE: If Type is referral/warm hand-off, complete referral list in Section C.

7 SECTION F. NON-MEDICAL OR FINANCIAL COUNSELING GOALS Primary Goal (select one) Anger Management Skills Caregiver Coping Skills Communication Skills (Couple/Marital) Communication Skills (Parent/Child) Communication Skills (School) Communication Skills (Workplace) Communication Skills (Social/Personal Conflict Resolution Skills Coping with Issues of Military Life Coping Skills Creating a Healthy Work Life Balance Decision-Making Skills Deployment Management Skills Developing Ways to Identify and Manage Caregiver Fatigue, Stress, and Burnout Education/Study/Learning Skills Progress Towards Goal (circle one) Met goal Partially Met Goal Did Not Meet Goal Financial Management Skills Grief Management Skills Healthy Living Skills Identifying Triggers, Life Stressors, and What Can/Cannot Be Done Parenting Skills Problem-Solving Skills Reintegration Skills Relationship Management Skills Relaxation Skills Relocation Adjustment Skills Sleep Management Skills Social/Interpersonal Skills Stress Management Skills Time Management Skills Transition Management Skills NOTE: Section F is only to be completed if this is the second session (or greater) with the primary participant, the primary participant is 18 years of age or younger, and the session lasts for 20 minutes or longer; OR if this is the second session (or greater) with the primary participant, the primary participant is 19 years of age or older, and the session lasts for 30 minutes or longer. Completed By: Signature: Date: NOTE: If you are unable to enter this data into the web or smart phone app, please fax completed forms to