2020 Guide to Evaluating Your CCP (Version 4.0) | i

CCP Data Collection Forms and Instructions (Version 4.0) Section 3

CCP Data Collection Forms and Instructions, 

Version 4.2

Section 3 of the Guide for 

Evaluating Your CCP
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | i

Table of Contents

Data Collection With the CCP Data Forms ................................................................................. 1

What are the sources of data? ...................................................................................................... 1

What are the CCP data collection forms? .................................................................................... 1

Basic tools...................................................................................................................................... 1

Additional tools.............................................................................................................................. 1

Basic Forms: Encounter Logs and Tallies .................................................................................. 1

What is their purpose? ................................................................................................................. 1

Individual/Family Crisis Counseling Services Encounter Log ................................................... 2

What is individual/family counseling?.......................................................................................... 2

What is in the Individual/Family Crisis Counseling Services Encounter Log?........................... 3

Review/Approve Pending Forms ................................................................................................. 4

When is it filled out?...................................................................................................................... 4

How do crisis counselors get the information for the Individual/Family Crisis Counseling 

Services Encounter Log?............................................................................................................... 5

How are families or multiple people treated? ............................................................................... 5

Relevant Research ......................................................................................................................... 5

Group Encounter Log .................................................................................................................. 7

What are group encounters?.......................................................................................................... 7

What’s in the Group Encounter Log? ........................................................................................... 7

Review/Approve Pending Forms ................................................................................................. 8

Relevant Research ......................................................................................................................... 8

Brief Educational and Supportive Services Not Elsewhere Included (Weekly Tally Sheet) ...... 9

What is the purpose of the Weekly Tally Sheet?.......................................................................... 9

What goes into the first section of the Weekly Tally Sheet?........................................................ 9

How is the week designated? ........................................................................................................ 9

How are hotline calls counted? ..................................................................................................... 9

How are mass media messages and social networking messages counted? ................................10

Relevant Research .........................................................................................................................10

Additional Forms: Assessments and Surveys ............................................................................... 11

What are the additional forms? .................................................................................................... 11

What is the purpose of the tools? ..................................................................................................11

How does a CCP prepare to use these tools?................................................................................11
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | ii

Assessment and Referral Tools ................................................................................................... 12

Why were the Adult Assessment and Referral Tool and the Child/Youth

Assessment and Referral Tool created?........................................................................................12

When and for whom are the Assessment and Referral Tools used? ............................................12

Adult Assessment and Referral Tool ........................................................................................... 13

How are adult symptoms assessed? ..............................................................................................14

Is the measure good? .....................................................................................................................14

How is the Adult Assessment and Referral Tool scored? ............................................................15

Is the Individual/Family Crisis Counseling Services Encounter Log used too? ..........................15

References (Adult Assessment and Referral Tool).......................................................................15

Relevant Research .........................................................................................................................16

Child/Youth Assessment and Referral Tool ................................................................................ 17

What’s in the Child/Youth Assessment and Referral Tool?.........................................................17

Referral Component ......................................................................................................................18

How is the Child/Youth Assessment and Referral Tool introduced by crisis counselors? .........18

How are child and youth symptoms assessed? .............................................................................19

Is the measure good? .....................................................................................................................19

How is it scored? ...........................................................................................................................19

Is the Individual/Family Crisis Counseling Services Encounter Log used too? ..........................19

References (Child/Youth Assessment and Referral Tool)............................................................19

Relevant Research .........................................................................................................................20

Participant Feedback Survey ....................................................................................................... 20

What is the Participant Feedback Survey?....................................................................................20

Why is this necessary?...................................................................................................................21

Who should complete the survey? ................................................................................................21

When is the survey done?..............................................................................................................21

How is the survey done? ...............................................................................................................21

What is the counselor’s role? ........................................................................................................22

How are counselors protected?......................................................................................................22

Service Provider Feedback Form ................................................................................................. 23

What is the purpose of this form? ................................................................................................. 23

Who is included? ...........................................................................................................................23

What’s in the Service Provider Feedback Form? .........................................................................23

When and how is it done? .............................................................................................................23
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | iii

How are counselors protected?......................................................................................................24

Relevant Research .........................................................................................................................24
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 1

Data Collection With the CCP Data Forms

What are the sources of data?

Crisis Counseling Assistance and Training Program (CCP) evaluation data come from many 

different sources. Data about event characteristics are found in the project’s grant application. 

Data about community characteristics are derived from the census. Standard statistics for 

ethnicity, race, age distribution, and percentage of people living in poverty can be recorded for 

each county. Data about activities (such as types of required CCP staff training) can be collected 

from program leaders. The remaining data on activities and outputs are collected throughout the 

program period by crisis counselors using the CCP data collection forms.

What are the CCP data collection forms?

The CCP data collection forms are a set of standardized forms completed by crisis counselors. 

Because the data are collected in a consistent way across all programs, they can be merged into a 

national database that the Substance Abuse and Mental Health Services Administration 

(SAMHSA) Center for Mental Health Services can use to produce summary reports of services 

provided across all funded projects. The utilization structure of the data collection forms might 

be described as a pyramid, involving tools that are used with decreasing frequency as you move 

from the base of the pyramid to the top (see Figure 1 on the next page). The basic tools include 

Individual/Family and Group Encounter Logs and Weekly Tallies. The advanced tools are 

Participant Feedback Surveys, Assessment and Referral Tools, and Service Provider Feedback 

Forms. The basic tools and Assessment and Referral Tools can be completed in the field using 

the PDF version of the forms or the CCP mobile application. The Participant Feedback Survey 

and Service Provider Feedback Form can be completed via PDF or electronically. 

Basic tools

 Include the Individual/Family Crisis Counseling Services Encounter Log, the Group

Encounter Log, and the Weekly Tally Sheet

 Are used frequently throughout the Immediate Services Program (ISP) and Regular

Services Program (RSP)

 Are used as soon as possible after a disaster

Additional tools

 Include the Service Provider Feedback Form, the Adult and Child/Youth Assessment and

Referral Tools, and the Participant Feedback Survey

 Are used occasionally

 Can be used in both the ISP and RSP, in consultation with CCP program management

Basic Forms: Encounter Logs and Tallies

What is their purpose?

Beginning as soon as feasible after the disaster and continuing through the ISP and RSP, these 

forms (those at the base of the pyramid in Figure 1) are used to document all services delivered. 

The forms are the basic and living record of the program and serve many purposes for program 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 2

monitoring and evaluation. It is very important for services to be counted in a standardized way 

across all areas served by the program. The forms are simple and take little time to complete.

The three types of forms that are to be completed by crisis counselors include (1) the 

Individual/Family Crisis Counseling Services Encounter Log, (2) the Group Encounter Log, and 

(3) the Weekly Tally Sheet: Brief Educational and Supportive Services Not Elsewhere Included

(Weekly Tally Sheet for short). In the sections that follow, each form is described.

Figure 1. Utilization Structure of CCP Data Collection Forms

Individual/Family Crisis Counseling Services Encounter Log

What is individual/family counseling?

Individual/family crisis counseling is focused on reducing stress, providing support, and 

improving coping skills. For the purposes of data collection and evaluation, individual crisis 

counseling is defined as an interaction that lasts at least 15 minutes and involves participant 

disclosure. This doesn’t mean that it should be only 15 minutes or that shorter interactions are 

discouraged.

Most of these encounters will take place in person, but they also include any virtual services that 

are conducted. For example, if a hotline contact otherwise meets the definition of individual or 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 3

family crisis counseling, the Individual/Family Crisis Counseling Services Encounter Log may be 

used. On the Individual/Family Encounter Log itself, show the location as “phone counseling” if 

it was an outbound call made by the crisis counseling staff. If this call was inbound from a 

participant, it should be logged as hotline, helpline, or crisis line. As with in-person crisis 

counseling encounters, these calls are tracked with an Individual/Family Encounter Log form if

they last 15 minutes or longer. 

There is a place on the form to record how long the encounter lasted.

What is in the Individual/Family Crisis Counseling Services Encounter Log?

The Individual/Family Crisis Counseling Services Encounter Log is a form with nine parts that is 

intended to capture details of encounters that are longer than 15 minutes. Crisis counselors 

complete this form immediately after the encounter when completing the PDF version or during 

the encounter when using the mobile app. When completing the mobile or PDF versions of the 

form, the crisis counselor is not expected to ask an individual for responses to these items; rather, 

crisis counselors complete the form based on their observations and interactions with the person 

during the encounter. The PDF version of the form can be found in the CCP Toolkit at 

www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings. 

Part 1 (Basic Information)

The first part collects information on the project number (Federal Emergency Management 

Agency [FEMA] disaster response number: DR-XXXX-state), provider name, both employee 

numbers, service date, county of service, and ZIP code of service delivery. Mobile app users will 

have some of the fields pre-populated in this section, while some questions will require a 

selection be made from a dropdown menu. 

Part 2 (Visit Type)

The second part collects information on the visit type. This includes the number of people who 

were involved in this encounter (one person or a family or household consisting of two or more 

individuals), visit number (first time or follow-up with anyone from the program), and duration 

of the encounter. Please note that a family visit type may include married or unmarried 

heterosexual, gay, lesbian, bisexual, or transgender individuals. 

Part 3 (Demographic Information)

The third part collects demographic information. This includes information on the number of 

males, females, and transgender persons per age category, as well as participants’ ethnicities, 

races, languages spoken, and disabilities or other access or functional needs, if any. Collection of 

this information is intended to be through observation. There is no need to directly ask 

participants these questions.

Part 4 (Location of Service)

The fourth part collects information on where the crisis counseling encounter took place. Many 

options are provided, including check boxes for whether children are living in the home, or 

whether the contact occurred over the phone. An “other” box provides the opportunity to specify 

a location type that is not otherwise listed (for example, a supply distribution center). 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 4

Part 5 (Risk Categories)

The fifth part collects information on risk categories. These are factors that individuals may have 

experienced or have present in their lives that could increase their need for crisis counseling or 

outreach services. Most of these risk factors are a result of the survivor’s disaster experience.

Part 6 (Event Reactions)

The sixth part collects information on reactions to the disaster event that the person (or family) is 

or are experiencing at the time of the service encounter. The form captures how many total people 

during the encounter displayed these reactions, and the various reactions are categorized as 

behavioral, emotional, physical, or cognitive. If a person is coping well with the disaster event at 

the time of the service encounter, then the crisis counselor can check the box indicating “coping 

well: None of the above apply.” 

Part 7 (Focus of Encounter)

The seventh part collects data on the discussion during the encounter, such as psycho-educational 

information provided, coping tips, and healthy connections offered to the survivor by the crisis 

counselor.

Part 8 (Materials Provided for This Encounter)

The eighth part documents whether the crisis counselor provided additional written information 

and materials to the survivor.

Part 9 (Referral)

The ninth and final part of the Individual/Family Crisis Counseling Services Encounter Log 

covers referral. A crisis counselor who has provided the person with a referral should indicate the 

referral type in this section. A referral could be to another component of the CCP, such as a 

support group, or to a team leader or senior professional for follow-up. The crisis counselor 

could also refer the consumer to other mental health services, substance use services, services 

related to access and functional needs, or community services, such as other FEMA Individual 

Assistance programs (housing, unemployment) if applicable. When the “other” option is used, 

the counselor should indicate the nature of the service rather than the agency to which the 

individual was referred. All referrals for mental health or substance use services should be 

indicated in the previous corresponding boxes. 

Review/Approve Pending Forms

Once the form has been entered into the system, or it has been uploaded to the system through 

the mobile application, the form will be placed in a pending queue. After a form is placed here, a 

team leader reviews it. Team leaders can approve or reject the form, allowing it to be included in 

“reporting” or “available for editing,” respectively.

When is it filled out?

When utilizing the PDF version of the form, crisis counselors or their partners should fill out the 

form immediately following the encounter. If using the mobile app, the form can be completed 

during an encounter. The best practice for completing forms during an encounter would be to 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 5

have one counselor participate and engage with the survivor while the other takes notes or begins 

filling out the encounter log form. For more guidance on completing forms during an encounter, 

please review the CCP mobile app data collection training video at 

www.youtube.com/watch?v=ZAagU0fVA-o&feature=youtu.be. 

Waiting until the end of the day to fill the logs out is not acceptable because the crisis counselor 

will not remember the answer to each question. Some people are seen more than once by a crisis 

counselor. The log is filled out for all counseling visits, not just the first, and the visit number is 

noted. Completed logs should be entered into the system and ready for review by the team leader 

at the end of each day or the beginning of the following day, if using the PDF version of the log. 

If the program is using the CCP mobile app, forms should be uploaded daily and reviewed by a 

team lead when the form reaches the pending queue in the desktop system. 

How do crisis counselors get the information for the Individual/Family Crisis Counseling 

Services Encounter Log?

Through active listening, crisis counselors engage service recipients in telling their stories in a 

way that reveals stressful experiences (risk factors) during or after the disaster. Some of the 

demographic characteristics (such as age) might be elicited by asking recipients how their family 

is doing. Because crisis counselors are encouraged to conduct outreach in pairs, it may be helpful 

for one crisis counselor to focus on taking notes or collecting data on the information obtained 

throughout the encounter, while the other takes the lead in engaging the survivor(s). This is not 

always possible, but when it is, it will help in ensuring accuracy when completing the log. 

How are families or multiple people treated?

Sometimes “individual” crisis counseling involves more than one person. Perhaps the crisis 

counselor has spoken to a married couple, a family, roommates, or even a couple of friends. This 

raises the issue of who the service recipient was in the counseling encounter. The service 

recipient is defined as any person who actively participated in the session (for example, by 

verbally participating), not someone who is merely present. There may be two or more 

individuals helped at the same time. To show how many people were involved in an encounter 

who are considered to be part of a family or household, crisis counselors should select the 

corresponding number for Family or Household. 

Relevant Research

 Adams, R. E. & Boscarino, J. A. (2013). Differences in mental health outcomes by 

acculturation status following a major urban disaster. International Journal of Emergency 

Mental Health, 15(2), 85.

 Agarwal, S., Ghosh, P. & Zheng, H. (2020). Consumption response to a natural disaster: 

Evidence of price and income shocks from Chennai Flood. SSRN. http://dx.doi.org/10.2139/

ssrn.3777641.

 Amdal, J. R. & Swigart, S. L. (2010). Resilient transportation systems in a post-disaster

environment: A case study of opportunities realized and missed in New Orleans and the 

Louisiana coastal region (No. 10-01). Gulf Coast Research Center for Evacuation and 

Transportation Resiliency.

 Anyamele, O. D., McFarland, S. M. & Fiakofi, K. (2021). The disparities on loss of 

employment income by US households during the COVID-19 pandemic. Journal of 

Economics, Race, and Policy. https://doi.org/10.1007/s41996-021-00086-1.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 6

 Brannen, D. E., Barcus, R., McDonnell, M. A., Price, A., Alsept, C. & Caudill, K.

(2013). Mental health triage tools for medically cleared disaster survivors: An evaluation

by MRC volunteers and public health workers. Disaster Medicine and Public Health

Preparedness, 7, 20-28.

 Clay, L. A., Papas, M. A., Gill, K. B. & Abramson, D. M. (2018). Factors associated

with continued food insecurity among households recovering from Hurricane Katrina.

International Journal of Environmental Research and Public Health, 15(8), 1647.

 Harley, D. A., Tiro, L. & Alfulayyih, M. (2018). Challenges after natural disaster for

rural residents with disabilities. In Disability and Vocational Rehabilitation in Rural

Settings (pp. 457-475). Springer, Cham.

 Hollander, A. C., Bruce, D., Burström, B. & Ekblad, S. (2011). Gender-related mental 

health differences between refugees and non-refugee immigrants-a cross-sectional registerbased

study. BMC Public Health, 11(1), 1–8.

 Jones, K., Allen, M., Norris, F. H. & Miller, C. (2009). Piloting a new model of crisis

counseling: Specialized crisis counseling services in Mississippi after Hurricane Katrina.

Administration and Policy in Mental Health and Mental Health Services Research, 36(3),

195.

 Loades, M. E., Chatburn, E., Higson-Sweeney, N., Reynolds, S., Shafran, R., Brigden, A.

& Crawley, E. (2020). Rapid systematic review: The impact of social isolation and

loneliness on the mental health of children and adolescents in the context of COVID-19.

Journal of the American Academy of Child & Adolescent Psychiatry, 59(11), 1218–1239.

doi:10.2105/AJPH.2012.300689.

 Pekevski, J. (2013). First responders and Psychological First Aid. Journal of Emergency

Management, 11, 39–48.

 Pfefferbaum, B. & North, C. S. (2016). Child disaster mental health services: A review of

the system of care, assessment approaches, and evidence base for intervention. Current

psychiatry reports, 18(1), 5.

 Riise, K. S., Hansel, T. C., Steinberg, A., Landis, R. W., Gilkey, S., Brymer, M. &

Speier, A. H. (2009). The Louisiana Specialized Crisis Counseling Services (SCCS):

Final program evaluation. Unpublished manuscript.

 Uekawa, K., Higgins, B., Golenbock, S., Mack, A. & Bellamy, N. (2016). Psychometric

properties of disaster event reaction items form the crisis counseling individual/family

log. Disaster Medicine and Public Health Preparedness, Aug 12, 1-10.

 Valenti, M., Fujii, S., Kato, H., Masedu, F., Tiberti, S. & Sconci, V. (2013). Validation of 

the Italian version of the Screening Questionnaire for Disaster Mental Health (SQD) in a 

post-earthquake urban environment. Annali dell’Istituto Superiore di Sanità, 49, 79–85.

 Yabe, H., Suzuki, Y., Mashiko, H., Nakayama, Y., Hisata, M., Niwa, S. I. & Abe, M.

(2014). Psychological distress after the Great East Japan Earthquake and Fukushima

Daiichi Nuclear Power Plant accident: Results of a mental health and lifestyle survey

through the Fukushima Health Management Survey in FY2011 and FY2012. Fukushima

Journal of Medical Science, 60(1), 57-67.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 7

Group Encounter Log

What are group encounters?

Group encounters are very important and appropriate for disaster survivors because of their 

shared experiences. The two types of group encounters are group crisis counseling and public 

education, and the differences between them are subtle. In group crisis counseling, service 

recipients do most of the talking. For example, in support groups, survivors meet to listen to each 

other and emotionally support one another, with the crisis counselor acting as a facilitator. In 

public education, the crisis counselor does most of the talking. For example, the crisis counselor 

may have made a presentation about common reactions to a disaster or shared updated 

community resource contacts. The Group Encounter Log is not to be used to document visits 

with family or household members. Visits with multiple people in the same household should

be documented using the Individual/Family Crisis Counseling Services Encounter Log. 

What’s in the Group Encounter Log?

Because of overlap in the information needed to describe them, group crisis counseling and 

public education encounter data are captured on the same form. The crisis counselor will check 

one box if the encounter was group counseling and another if it was public education. The log 

has five parts. The PDF version of the form can be found in the CCP Toolkit at 

www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings. 

Part 1 (Basic Information)

The first part of the log collects information on the program, including project number (FEMA 

disaster response number: DR-XXXX-state), provider name, employee number(s), service date,

county of service, and ZIP code of service. As with the Individual/Family Encounter Log, some 

of this information will normally be pre-populated when completing forms in the mobile 

application. 

Part 2 (Type of Service)

The second part captures whether the group encounter was group counseling or public education.

Part 3 (Characteristics of Encounter)

The third part collects information on the location of the encounter and its session number (first 

session of a group expected to meet once, first session of a group expected to meet more than 

once, or a second or later session of an ongoing group). The estimated number of participants by 

age group and the duration of the encounter are also recorded on this part of the Group 

Encounter Log. 

Part 4 (Group Identities)

This section basically asks, “What makes the group a group?” Options are provided for the crisis 

counselor to check if a group consisted only or mostly of children or youth, adult disaster 

survivors, public safety workers and first responders, or other recovery workers. There is also an 

option to select if a group encounter was composed of a mixture of the previous list or had no 

clear group identity. The crisis counselor can note what ethnicities or races were represented 

within the group, and there is also a question to capture whether any of the participants had a 

disability or other access or functional need. 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 8

Part 5 (Focus of the Group Session)

The fifth part asks the counselor to describe the focus of the group session by making selections 

of one or more of the several options provided on the form that apply. For example, the crisis 

counselor can indicate that the purpose of the group was to present information and provide 

education about one or more of the following: (1) reactions to disaster, (2) community resources, 

and (3) the crisis counseling program. The crisis counselor may also indicate that tips on various 

topics, information about healthy connections, and materials were provided to the group. 

Review/Approve Pending Forms

Once a form has entered the system, whether by manual entry or via upload from the mobile app, 

the form will be placed in a pending queue. After a form is placed in the queue, a team leader 

reviews it and approves or rejects it, which makes it ready for inclusion in reporting (if

approved) or available for editing (if rejected).

Relevant Research

 Boscarino, J. A. (2015). Community disasters, psychological trauma, and crisis intervention. 

International Journal of Emergency Mental Health, 17(1), 369–

371.

 Brom, D., Baum, N. L. & Pat-Horenczyk, R. (2015). Systems of care for traumatized

children: The example of a school-based intervention model. In Future Directions in PostTraumatic Stress Disorder (pp. 155-169). Springer US.

 Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M.J. &

Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma

intervention: Empirical evidence. Psychiatry, 70(4), 283-315. Retrieved from

www.psychiatry.org.

 Jacobs, G. A., Gray, B. L., Erickson, S. E., Gonzalez, E. D. & Quevillon, R. P. (2016).

Disaster mental health and community‐based psychological first aid: Concepts and

education/training. Journal of Clinical Psychology, 72(12), 1307-1317.

 North, C., King, R., Fowler, R., Kucmierz, R., Wade, J., Hogan, D. & Carlo, J. (2015).

Delivery of mental health care in a large disaster shelter. Disaster Medicine and Public

Health Preparedness, 9(4), 423-429. doi:10.1017/dmp.2015.63.

 North, C. S. & Pfefferbaum, B. (2013). Mental health response to community disasters: A

systematic review. Jama, 310(5), 507-518.

 Olff, M. (2015). Mobile mental health: A challenging research agenda. European Journal of 

Psychotraumatology, 6(1), 27882.

 Pfefferbaum, B., Sweeton, J. L., Nitiéma, P., Noffsinger, M. A., Varma, V., Nelson,

S. D. & Newman, E. (2014). Child disaster mental health interventions: Therapy

components. Prehospital and Disaster Medicine, 29(5), 494–502.

http://doi.org/10.1017/S1049023X14000910.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 9

Brief Educational and Supportive Services Not Elsewhere Included 

(Weekly Tally Sheet)

What is the purpose of the Weekly Tally Sheet?

Crisis counselors engage in many activities that are not captured by the Individual/Family Crisis 

Counseling Services Encounter Log or Group Encounter Log, but that are nonetheless important. 

For these other activities, crisis counselors use the Brief Educational and Supportive Services

Not Elsewhere Included Weekly Tally Sheet (Weekly Tally Sheet for short). This includes, for 

example, brief interactions, phone calls or email exchanges, distribution of materials, community 

networking and coalition building, mass media messages, and social networking messages. Daily 

and weekly totals are recorded. The PDF version of the form can be found in the CCP Toolkit at 

www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings. 

What goes into the first section of the Weekly Tally Sheet?

The first part collects general information, including the project number (FEMA disaster response 

number: DR-XXXX-state), provider name, county or parish, the start date of the week for which 

data are recorded on the form, and the employee ID. Mobile app users will have some of the 

fields pre-populated in this section, while some questions will require a selection be made from a 

dropdown menu. 

How is the week designated?

The week should always be designated by Sunday’s date. For example, a part-time crisis 

counselor working on Friday and Saturday should use the previous Sunday’s date. 

Once a form has entered the system, whether by manual entry or via upload from the mobile app, 

the form will be placed in a pending queue. Once a form is in this queue, a team leader can 

review it and approve or reject it. If he or she approves the form, it will be ready for inclusion in 

reporting. If the team leader rejects the form, it will be available for editing.

How are hotline calls counted?

Disaster-related hotline contacts may be counted as CCP services if (1) the services have been 

paid for by the grant, and (2) the hotline contractor has been issued a provider number. If the state 

has hired a specific staff member to answer hotline calls for the CCP, then an employee number 

will be issued. There must be a system in place for assessing and documenting which hotline calls 

are related to disaster survivors. If hotline calls are recorded on the Weekly Tally Sheet, they are 

indicated in one of two ways: If a phone call was received on an established hotline, helpline, or 

lifeline, it is noted in that row (“hotline/helpline/lifeline contact”), but if a call is made by a crisis 

counselor, it is noted as a telephone contact (“telephone contact by crisis counselors”). To be 

recorded on the Weekly Tally Sheet, the call must last less than 15 minutes.

This protocol must be documented and provided to the federal project officers for the CCP grant 

as part of routine and ongoing progress calls and quarterly and final reports. 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 10

How are mass media messages and social networking messages counted?

CCP staff members should include the number of individual mass media or social media 

messages broadcast or posted—not the number of listeners or followers—on the appropriate lines

of the Weekly Tally Sheet.

If a mass media message is broadcast to a large audience, that number may be counted within the 

narrative of the CCP quarterly or final reports—but should not be noted on the Weekly Tally 

Sheet form.

For social media messaging, the number of people reached by the messages can be recorded

under the social media impressions/reach or engagement lines. Any additional data on the reach 

or impact of a social media campaign should be included within the narrative of the CCP

quarterly or final reports.

Relevant Research

 Beaudoin, C. E. (2009). Evaluating a media campaign that targeted PTSD after

Hurricane Katrina. Health Communication, 24(6), 515-523.

doi:10.1080/10410230903104905.

 Frank, R. G., Pindyck, T., Donahue, S. A., Pease, E. A., Foster, M. J., Felton, C. J. &

Essock, S. M. (2006). Impact of a media campaign for disaster mental health

counseling in post-September 11 New York. Psychiatric Services, 57(9), 1304-1308.

doi:10.1176/appi.ps.57.9.1304.

 Houston, J. B., First, J., Spialek, M. L., Sorenson, M. E. & Koch, M. (2016). Public

disaster communication and child and family disaster mental health: A review of

theoretical frameworks and empirical evidence. Current Psychiatry Reports, 18(6),

54.

 Jurgens, M. & Helsloot, I. (2017). The effect of social media on the dynamics of (self) 

resilience during disasters: A literature review. Journal of Contingencies and Crisis 

Management, 26(1), 79–

88. https://doi.org/10.1111/1468-5973.12212.

 Naturale, A., Lowney, L. T. & Brito, C. S. (2017). Lessons learned from the Boston

Marathon bombing victim services program. Clinical Social Work Journal, 45(2), 111-

123.

 North, C., King, R., Fowler, R., Kucmierz, R., Wade, J., Hogan, D. & Carlo, J. (2015).

Delivery of mental health care in a large disaster shelter. Disaster Medicine and Public

Health Preparedness, 9(4), 423-429. doi:10.1017/dmp.2015.63.

 Yates, D. & Paquette, S. (2011). Emergency knowledge management and social media

technologies: A case study of the 2010 Haitian earthquake. International Journal of

Information Management, 31(1), 6-13. doi:10.1016/j.ijinfomgt.2010.10.001.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 11

Additional Forms: Assessments and Surveys

What are the additional forms?

The additional forms include the following:

 Adult Assessment and Referral Tool

 Child/Youth Assessment and Referral Tool

 Participant Feedback Survey

 Service Provider Feedback Form

The Assessment and Referral Tool forms can be used at any point in the program, if the crisis 

counselor feels their use is warranted. The Participant Feedback Surveys and Service Provider 

Feedback Form surveys are administered twice, at six and 12 months after the disaster incident, 

and usually during the RSP grant. 

What is the purpose of the tools?

The Adult and Child/Youth Assessment and Referral Tools and the Participant Feedback Survey 

collect more in-depth information about service recipients than is captured by the 

Individual/Family Crisis Counseling Services Encounter Log, the Group Encounter Log, and the 

Weekly Tally Sheet. The Service Provider Feedback Form measures the opinions, experiences, 

and perceived stress of crisis counselors and their supervisors.

How does a CCP prepare to use these tools?

Assessment and Referral Tools

The CCP should have protocols or procedures in place for how a crisis counselor should respond 

if serious reactions are indicated while using the Assessment and Referral Tools. Many CCPs 

have team leaders or other staff with a mental health background administer the tools to ensure 

that proper assessment and referral is carried out. All crisis counseling staff using the tools 

should have detailed training and guidance on use of the tool and when to make a referral for 

more intensive services. Prior to use of this tool, the CCP should have identified at least one 

organization or agency that is willing to accept referrals from the CCP for more intensive mental 

health or substance use intervention services.

Prior to administration of the Child/Youth Assessment and Referral Tool, consent must be 

obtained from a parent or other caregiver for the child’s or youth’s participation in the CCP.

For babies and children from less than 1 to 7 years old, it is recommended that a parent or other 

caregiver be interviewed with the child present (Cohen, Kelleher & Mannarino, 2008; 

Scheeringa & Haslett, 2010). When there are concerns about the ability of a child over the age of 

7 to understand and accurately answer the questions, it is advisable for the parent or other 

caregiver to assist in answering the questions. For children over 7 years of age, crisis counselors 

should get verbal consent from the parent or other caregiver. Adolescents may not want to be 

interviewed in front of their parents. If a parent or other caregiver is present, ask the adolescent if 

he or she wishes to be interviewed alone.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 12

Feedback Surveys

The CCP will identify a one- or two-week period at six and 12 months after the disaster during 

which the Participant Feedback Survey will be disseminated to all survivors participating in an 

individual or family crisis counseling encounter or a group counseling session. The CCP will 

either need to print copies of the survey and prepare pre-stamped envelopes for survivors to use 

to mail in the surveys or be prepared to distribute the weblink generated by the SAMHSA 

Disaster Technical Assistance Center (DTAC) for survivors to complete the surveys online. If 

utilizing printed surveys, the envelope should be addressed to the designated staff at the CCP 

who will enter the data into the CCP Online Data Collection and Evaluation System (ODCES).

As for the Service Provider Feedback Form survey, the CCP will identify a one- or two-week

period at six and 12 months after the disaster during which the Service Provider Feedback Form 

will be administered. The CCP will contact SAMHSA DTAC to set up an online link to the 

Service Provider Feedback Form. The CCP will be responsible for disseminating the link to 

direct service staff. If a CCP grant program prefers paper administration, it may contact 

SAMHSA DTAC at 800-308-3515 or dtac@iqsolutions.com for details and guidance on 

administration.

Assessment and Referral Tools

Why were the Adult Assessment and Referral Tool and the Child/Youth Assessment 

and Referral Tool created?

Crisis counseling programs focus on short-term mental health and substance use-related 

interventions, but some people need either longer or more intensive interventions. A key service 

provided by the CCP grants is identifying and referring people who may need additional 

services to other mental health programs for services or treatment. Sometimes more intensive 

interventions are offered in collaboration with CCPs, but more often crisis counselors need to 

rely on other community and state programs. Research on early CCPs suggested that referring

people to more intensive mental health and substance use services was a problem area for many 

providers. The issues ranged from limited availability of services (which, of course, cannot be 

addressed by means of a tool) to uncertainty about when to make referrals. The Adult and 

Child/Youth Assessment and Referral Tools were created to help CCPs and crisis counselors in 

making these referrals. They also help to remind them that if individuals are not getting better, 

they should (and can) be referred for more intensive help. 

When and for whom are the Assessment and Referral Tools used?

Typically, the Adult and Child/Youth Assessment and Referral Tools are used with all adults and 

children or youth who are potential intensive users of services. Intensive users are people who 

are participating in their third or fifth individual crisis counseling visit with any crisis counselor 

from the program or who continue to suffer severe distress that may be impeding their ability to 

perform routine daily activities. There may be occasions when the crisis counselor believes the 

tools should be used before the third visit; this is recommended if the crisis counselor believes

that someone is experiencing serious reactions. For further guidance on when and how to use 

these tools, please review the Assessment and Referral Tool training video at 

www.youtube.com/watch?v=flei8krbcs0. 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 13

Adult Assessment and Referral Tool

What’s in the Adult Assessment and Referral Tool?

Part 1 

As with the other forms, the first part may be pre-filled, or selections can be filled in, to include 

basic information on the program, such as project number (FEMA disaster response number: 

DR- XXXX-state), provider name, both employee numbers, service date, and county and ZIP 

code of service. Below this basic information section, the form is similar to the 

Individual/Family Crisis Counseling Services Encounter Log, which also includes places to 

record location of service, risk categories, demographic information, and if a team lead or 

supervisor was present. For users of the mobile app, the Assessment and Referral Tool forms are 

subforms linked to the Individual/Family Crisis Counseling Services Encounter Log. All of the 

demographic questions from Part 1 will be automatically filled into the uploaded assessment

form, reflecting the choices made on corresponding portions of the Individual/Family Crisis 

Counseling Services Encounter Log. 

Part 2 

The second page of the form instructs the crisis counselor to read an introductory statement:

“These questions are about the reactions you have experienced IN THE PAST MONTH. By 

reactions, I mean feelings or emotions or thoughts about the events. For each question choose 

one of the following responses from this card.”

The response card is available in the CCP Toolkit at www.samhsa.gov/dtac/ccp-toolkit/ccp-dataforms-trainings and shows the respondent the choices for answering the statements. Responses 

for the Adult Assessment and Referral Tool are as follows: 1 = Not at all, 2 = A little bit, 3 = 

Somewhat, 4 = Quite a bit, and 5 = Very much. The crisis counselor indicates the respondent’s 

answer and concludes with a score of the total number of responses that were indicated with a 4 

or 5. 

Referral Component

If the respondent answers “yes” to items 12–14, the crisis counselor should immediately refer 

the person for professional psychiatric or other mental health intervention. The CCP should 

have protocols or procedures in place for how a crisis counselor should respond or react if such 

an event occurs. Many CCPs have team leaders or other staff with a mental health background to 

administer this tool to ensure that proper assessment and referral are carried out. All crisis 

counseling staff using this tool should have detailed training and guidance on use of the tool and 

when to make a referral for more intensive services. Prior to use of this tool, the CCP should 

have identified at least one organization or agency that is willing to accept referrals from the 

CCP for more intensive mental health or substance use intervention services.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 14

If the answer to items 12-14 is “no,” then the crisis counselor should continue as follows:

 If the total score is 3 or higher, the counselor should be prepared to offer the respondent

the name of the organization and a contact at the organization that has agreed to accept

CCP referrals.

 If the total score is below 3, the counselor then determines whether the respondent can

manage his or her reactions. The counselor can still offer referral information or work

with the person to decide upon specific goals for counseling that can be completed within

a couple of visits.

The last part of the Adult Assessment and Referral Tool that the crisis counselor is to complete is 

similar to the referral section on the Individual/Family Crisis Counseling Services Encounter 

Log. The counselor selects the type of referral provided and indicates whether the person 

accepted the referral. The PDF version of the form can be found in the CCP Toolkit at 

www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings.

How are adult symptoms assessed?

The reaction section of the tool (part 2, items 1 through 11) was adapted from the Short PostTraumatic Stress Disorder Rating Interview (SPRINT) developed by Connor and Davidson. With 

the permission of Connor and Davidson, the measure was modified for the CCP Project Liberty’s 

use after the terrorist attacks of Sept. 11, 2001 (SPRINT-Expanded or Sprint-E) (Connor & 

Davidson, 2001). The Sprint-E assesses posttraumatic stress, health risk behavior, stress 

vulnerability, and functional impairment. Questions addressing suicidal ideation (items 12-14) 

are not included in the score. Rather, they are included in the scale as a precaution, and crisis 

counselors are instructed to refer respondents for immediate psychiatric intervention if they 

answer “yes” to any of the questions.

Is the measure good?

Data from 788 clients in Project Liberty indicated that the Sprint-E was a reliable measure of 

need for intervention as expressed in distress and dysfunction (Norris et al., 2006). Of those 

offered referral according to their score on the tool, 71 percent accepted. Among those offered 

referral, the number of intense reactions was by far the strongest predictor of referral acceptance. 

Many of the attributes of the Sprint-E (brevity, simplicity of administration, focus on intense 

reactions, and emphasis on function and subjective need) emerged because it was developed 

collaboratively by researchers and leaders of Project Liberty. In this study of 788 adults in crisis 

counseling two years after 9/11, the Sprint-E was found to be equally reliable (α = 0.93) across 

ethnic groups in the sample (Norris et al., 2006). A criterion of three intense reactions was set as 

the initial guideline for referral to treatment in New York (Norris et al., 2006). Referral 

acceptance increased in a linear fashion in relation to the number of intense reactions until it 

peaked and stabilized at seven intense reactions (85 percent acceptance). This result led to a 

working “3/7 rule” for the Sprint-E. According to this rule, if a person responds with three 

ratings of 4 (quite a bit) or 5 (very much) to questions on distress and dysfunction, he or she may 

need treatment. If a person responds to questions on distress and dysfunction with seven 4 or 5 

ratings, he or she probably needs treatment. The validity of the “3/7 rule” was supported in a 

sample of help-seeking adults in Florida after the 2004 hurricanes. Tested against the 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 15

Posttraumatic Stress Disorder (PTSD) Checklist, the Sprint-E performed well in receiver 

operating characteristic, or ROC, analyses (area under the curve = 0.87); a score of seven 

achieved sensitivity of 78 percent and specificity of 79 percent (Norris, Hamblen, Brown & 

Schinka, 2008). 

The Sprint-E was subsequently used in a treatment program for Hurricane Katrina survivors 

sponsored by the Baton Rouge Area Foundation, in collaboration with the Baton Rouge Crisis 

Intervention Center and the National Center for PTSD. The Sprint-E was administered at the 

point of referral and at four subsequent points in time following the disaster. Participants’ scores 

decreased greatly during the course of treatment, and improvements were maintained at a fourmonth follow-up. The Sprint-E’s reliability and sensitivity to change were also evidenced in a 

study of specialized crisis counseling services in Mississippi (Jones, Allen, Norris & Miller, 

2009; Hamblen, et al., 2009) (full references are at the end of this section).

How is the Adult Assessment and Referral Tool scored?

The response card is located in the CCP Toolkit, at www.samhsa.gov/dtac/ccp-toolkit/ccpdata-forms-trainings. As noted, responses to the questions in this section are as follows: 1 = 

Not at all, 2 = A little bit, 3 = Somewhat, 4 = Quite a bit, and 5 = Very much. The tool is 

scored by counting the number of reactions valued 4 (quite a bit) or 5 (very much). It has been

structured in a way that makes the scoring straightforward.

Is the Individual/Family Crisis Counseling Services Encounter Log used too?

If a crisis counselor is completing the Assessment and Referral Tool, there is no need to also 

complete the Individual/Family Encounter Log. Much of the information is duplicative between 

the two forms, despite the forms’ being used for different purposes. If using the PDF version of 

the form, a separate assessment will be done for each applicable participant in an encounter. 

When using the mobile app, the Individual/Family Encounter Log demographic and encounterspecific sections only need to be completed once, no matter how many assessments are 

completed.

References (Adult Assessment and Referral Tool)

 Connor, K. M. & Davidson, J. R. (2001). SPRINT: A brief global assessment of posttraumatic stress disorder. International Clinical Psychopharmacology, 16(5), 279–284.

 Hamblen, J. L, Norris, F. H., Pietruszkiewicz, S., Gibson, L. E, Naturale, A. & Louis, C.

(2009). Cognitive behavioral therapy for postdisaster distress: A community based

treatment program for survivors of Hurricane Katrina. Administration and Policy in

Mental Health and Mental Health Services Research, 36(3), 206–214.

 Jones, K., Allen, M., Norris, F. H. & Miller, C. (2009). Piloting a new model of crisis 

counseling: Specialized crisis counseling services in Mississippi after Hurricane Katrina. 

Administration and Policy in Mental Health and Mental Health Services Research, 36,195– 

205.

 Norris, F. H., Donahue, S.A., Felton, C. J., Watson, P. J., Hamblen, J. L. & Marshall, R.D. 

(2006). A psychometric analysis of Project Liberty’s adult enhanced services referral tool. 

Psychiatric Services, 57(9), 1328–1334.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 16

 Norris, F. H., Hamblen, J. L., Brown, L. M. & Schinka, J. A. (2008). Validation of the

Short Post-Traumatic Stress Disorder Rating Interview (expanded version, Sprint-E) as a

measure of postdisaster distress and treatment need. American Journal of Disaster

Medicine, 3(4), 201–212.

Relevant Research

 Brown, L. M., Framingham, J. L., Frahm, K. A. & Wolf, L. D. (2015). Crisis counselors’

perceptions and assessment of suicidal behavior among hurricane survivors receiving

crisis counseling services. Disaster Medicine and Public Health Preparedness, 9(3), 291-

300.

 Connor, K. & Davidson, J. (2001). SPRINT: A brief global assessment of post-traumatic

stress disorder. International Clinical Psychopharmacology, 16, 279–284.

 Fox, J. H., Burkle, F. M., Jr., Bass, J., Pia, F. A., Epstein, J. L. & Markenson, D. (2012).

The effectiveness of Psychological First Aid as a disaster intervention tool: Research

analysis of peer-reviewed literature from 1990 to 2010. Disaster Medicine and Public

Health Preparedness, 6, 247–252.

 James, L. E. & Noel, J. R. (2013). Lay mental health in the aftermath of disaster: Preliminary 

evaluation of an intervention for Haiti earthquake survivors. International Journal of Emergency 

Mental Health, 15, 165–178.

 Hamblen, J. L., Norris, F. H., Symon, K. A. & Bow, T. E. (2017). Cognitive behavioral

therapy for postdisaster distress: A promising transdiagnostic approach to treating

disaster survivors. Psychological Trauma: Theory, Research, Practice, and Policy,

9(S1), 130.

 Horowitz, L. M., Snyder, D., Ludi, E., Rosenstein, D. L., Kohn-Godbout, J., Lee, L.,

Cartledge, T., Farrar, A. & Pao, M. (2013). Ask suicide-screening questions to everyone

in medical settings: The asQ’em Quality Improvement Project. Psychosomatics, 54(3),

239-47.

 Krishnaswamy, S., Subramaniam, K., Indran, T. & Low, W. Y. (2012). The 2004

tsunami in Penang, Malaysia: Early mental health intervention. Asia-Pacific Journal of

Public Health, 4, 710–718.

 NIMH Ask Suicide-Screening Questions (ASQ) Toolkit. (n.d.) Retrieved from

https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkitmaterials/index.shtml.

 Otsuka, K., Sakai, A., Nakamura, H. & Akahira, M. (2014). After the Great East Japan

Earthquake: Suicide prevention and a gatekeeper program. Seishin Shinkeigaku Zasshi,

116, 196–202.

 Riise, K. S., Hansel, T. C., Steinberg, A. M., Landis R. W., Gilkey S., Brymer, M. J., et

al. (2009). The Louisiana Specialized Crisis Counseling Services (SCCS): Final program

evaluation. Unpublished manuscript.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 17

Child/Youth Assessment and Referral Tool

What’s in the Child/Youth Assessment and Referral Tool?

Part 1 

As with the other CCP forms, the first part may be filled out prior to the visit, or selections can 

be made from the dropdown menus, including project number (FEMA disaster response number: 

DR-XXXX-state), provider name, provider number, employee number(s), date of service, county 

of service, and ZIP code of service. When the visit starts, fill in the visit number and indicate 

whether a team leader or supervisor, as well as parent or caregiver, is present during the visit. 

Below the Encounter Information section, there is a section to document the location of service, 

and then a Risk Categories section that allows you to check off how children and adolescents 

were affected by the disaster and its aftermath. The last section on this page is a Demographic 

Information section to enter basic characteristics of the child being interviewed. The PDF

version of the form can be found in the CCP Toolkit at www.samhsa.gov/dtac/ccp-toolkit/ccpdata-forms-trainings. 

For users of the mobile app, the Assessment and Referral Tool forms are subforms linked to the 

Individual/Family Crisis Counseling Services Encounter Log. All the demographic questions 

from Part 1 will be automatically filled into the uploaded assessment form, reflecting the choices 

made on corresponding portions of the Individual/Family Crisis Counseling Services Encounter 

Log.

Part 2 

The second page of the form instructs the crisis counselor to read an introductory statement:

“I want to talk to you about your (your child’s) feelings and thoughts about the disaster and how 

much they are causing problems now. Think about your thoughts, feelings, and behavior 

DURING THE PAST MONTH. For each question, choose ONE of the following responses

and check the appropriate box for that question.”

The response card is shown on page 2 of the Child/Youth Assessment and Referral Tool. It is 

also located in the CCP Toolkit at www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings. 

Responses to the questions in this section are as follows: 0 = Not at all, 1 = A little bit, 2 = 

Somewhat, 3 = Quite a bit, and 4 = Very much. 

For questions 1-15, read each item aloud and have the child or youth, or his or her caregiver, 

identify how often the child has experienced these feelings, thoughts, or behaviors in the past 

month by pointing on the response card to the choice that best fits. For younger children, the 

crisis counselor may have to help the child understand how long a month has been by identifying 

something in the child’s life that occurred a month ago (e.g., a holiday, school break, tests, or a 

family event). Then the crisis counselor can say, for example, “Since spring break, then [read the 

item].”

Starting on page 3, questions 16-20 are to be asked of a parent or other caregiver. These 

questions are required for children of less than 1 year old through age 7 and recommended for 

all children and adolescents. The response choices for these questions are the same as for

questions 1-15.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 18

The crisis counselor fills in the respondent’s answers to each item on the second and the third 

pages and then totals the number of items (from both pages) that were scored 3 or 4. If the total

number is four or more, the crisis counselor should discuss the possibility of a referral for more 

services.

For children over the age of 10 (or if the crisis counselor or parent or other caregiver is 

concerned about a younger child), the counselor should ask items 21-24 relating to suicidal 

ideation. If the child answers yes to any of those questions, the counselor should also ask, 

“Are you having thoughts of killing yourself right now?” If the respondent answers “yes” 

to this item, then the crisis counselor should immediately refer the child/youth for 

psychiatric or other mental health professional intervention. The CCP should have protocols 

or procedures in place for how a crisis counselor should respond and who should be notified of 

this safety concern. Many CCPs have team leaders or other staff with a mental health 

background to ensure that proper assessment and referral are carried out. All crisis counseling 

staff using this tool should have detailed training and guidance on use of the tool and when to 

make a referral for more intensive services. Prior to use of this tool, the CCP should have 

identified an organization or agency that is willing to accept referrals from the CCP for 

immediate psychiatric intervention.

Referral Component

If the total number is four or higher, the counselor should discuss appropriate referral options 

for the child or youth. This includes being prepared to offer youth and parents the name at an 

organization that has agreed to accept CCP referrals and a contact at that organization. If the total 

number is three or fewer, the counselor can recommend either another visit with him- or herself 

(the counselor) or provide a referral if the child or youth needs specific support or intervention.

In the Referral section, check the type of referral made, if the person (child or youth) accepted 

the referral, and if the parent or other caregiver accepted the referral.

How is the Child/Youth Assessment and Referral Tool introduced by crisis counselors?

Prior to administration of the Child/Youth Assessment and Referral Tool, make sure that consent 

was obtained from a parent or other caregiver for the child’s or youth’s participation in the CCP.

For children over the age of 7 read the following instructions:

“Occasionally, we find it helpful to ask children/adolescents or their parents/caregivers a few 

specific questions about how they were affected by the disaster and how they are feeling now. 

May I ask you these questions? My first questions are about various experiences you have had 

in the disaster.”

For children of less than 1 year old to age 7, it is recommended that a parent or other caregiver 

be interviewed with the child present (Cohen, Kelleher & Mannarino, 2008; Scheeringa & 

Haslett, 2010). When there are concerns about the ability of a child over the age of 7 to 

understand and accurately answer the questions, it is advisable for the parent or other caregiver 

to assist in answering the questions.

Adolescents may not want to be interviewed in front of their parents. If a parent or caregiver is 

present, ask the adolescent if he or she wishes to be interviewed alone.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 19

How are child and youth symptoms assessed?

The symptom (or reaction) section of the tool (pages 2-3, items 1-20) was adapted from the 

University of California, Los Angeles PTSD Reaction Index (Steinberg, Brymer, Decker & 

Pynoos, 2004) with the addition of items related to depression and functioning. Drs. Pynoos and 

Steinberg granted permission for this modification for use by the CCP Project Liberty after the 

terrorist attacks on Sept. 11, 2001. This tool was then further modified for use by the Louisiana 

Spirit Specialized CCP after Hurricanes Katrina and Rita.

Is the measure good?

Using this referral tool, over 70 percent of children and adolescents initially screened for the 

Louisiana Spirit Specialized CCP and given a referral accepted the referral (Riise, et al., 2009). 

This finding was slightly higher than referral acceptance in Project Liberty (60 percent of 

children provided with a referral accepted it), which used an earlier version of the assessment 

tool. For the referral tool in general, items had good internal consistency and showed a strong 

relationship with referral acceptance (Kronenberg, et al., 2010). 

How is it scored?

The tool is scored by counting the number of items (page 2-3, questions 1-20) that have a value 

of 3 (quite a bit) or 4 (very much). The tool has been structured in a way that makes the scoring 

straightforward. If the total number is 4 or higher, the counselor should discuss appropriate 

referral options for the child or youth. This includes being prepared to offer youth and parents 

the name of an organization that has agreed to accept CCP referrals and a contact at that 

organization. If the total number is 3 or fewer, the counselor can still recommend a referral if the 

child or youth needs specific support or intervention. The counselor may also recommend that 

the child or youth visit again with him or her (the current counselor). 

Is the Individual/Family Crisis Counseling Services Encounter Log used too?

If a crisis counselor is completing the Assessment and Referral Tool, there is no need to also 

complete the Individual/Family Encounter Log. Much of the information is duplicative between 

the two forms, despite the forms’ being used for different purposes. If using the PDF version of 

the form, a separate assessment will be done for each applicable participant in an encounter. 

With the mobile app, the Individual/Family Encounter Log demographic and encounter-specific 

sections only need to be completed once, no matter how many assessments are completed.

References (Child/Youth Assessment and Referral Tool)

 Cohen, J. A., Kelleher, K. J. & Mannarino, A. P. (2008). Identifying, treating, and referring 

traumatized children: The role of pediatric providers. Archives of Pediatrics and Adolescent 

Medicine, 162(5), 447–452.

 Kronenberg, M. E., Hansel, T. C., Brennan, A. M., Osofsky, H. J., Osofsky, J. D. &

Lawrason, B. (2010). Children of Katrina: Lessons learned about postdisaster symptoms

and recovery patterns. Child Development, 81(4), 1241–1259.

 Riise, K. S., Hansel, T. C., Steinberg, A. M., Landis R. W., Gilkey S., Brymer, M. J. &

Speier, A. H. (2009). The Louisiana Spirit Specialized Crisis Counseling Services

(SCCS): Final program evaluation. Hurricane Katrina RSP DR-1603-LA. Unpublished

manuscript.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 20

 Scheeringa, M. S. & Haslett, N. (2010). The reliability and criterion validity of the

diagnostic infant and preschool assessment: A new diagnostic instrument for young

children. Child Psychiatry and Human Development, 41(3), 299–312.

 Steinberg, A. M., Brymer, M. J., Decker, K. B. & Pynoos, R. S. (2004). The University of 

California at Los Angeles Post-traumatic Stress Disorder Reaction Index. Current

Psychiatry Reports, 6, 96–100.

Relevant Research

 Horowitz, L. M., Snyder, D., Ludi, E., Rosenstein, D. L., Kohn-Godbout, J., Lee, L.,

Cartledge, T., Farrar, A. & Pao, M. (2013). Ask suicide-screening questions to everyone in 

medical settings: The asQ’em Quality Improvement Project. Psychosomatics, 54(3),

239-47.

 Navarro, J., Pulido, R., Berger, C., Arteaga, M., Osofsky, H. J., Martinez, M. & Hansel, T. 

C. (2014). Children’s disaster experiences and psychological symptoms: An international 

comparison between the Chilean earthquake and tsunami and Hurricane Katrina. 

International Social Work, 1, 14.

 Nash, C., Hawkins, A., Kawchuk, J., Shea, S. (2012). What’s in a name? Attitudes

surrounding the use of the term ‘mental retardation.’ Paediatrics & Child Health,

17(2), 71-74.

 Rousseau, C., Measham, T. & Nadeau, L. (2013). Addressing trauma in collaborative

mental health care for refugee children. Clinical Child Psychology and Psychiatry, 18,

121–136.

Participant Feedback Survey

What is the Participant Feedback Survey?

This questionnaire seeks feedback and other information from service recipients. The questions 

about services relate directly to the goals of crisis counseling, such as providing reassurance and 

help with finding ways to cope. The first two sections include questions to gauge what kinds of 

services were received and whether those services were helpful. Also included in the survey are 

questions about how helpful the CCP was to the recipient and experiences the recipient had of or 

in relation to the disaster. Part of the survey collects information on event reactions, such as 

posttraumatic stress, depression, impaired functioning, and perceived need for additional help. 

(This is the Sprint-E, described earlier as part of the Adult Assessment and Referral Tool). A 

brief statement to respondents invites them to speak with a counselor if they would like to do so, 

or if they have concerns about their reactions to the disaster. A local phone number should be 

included on the form for this purpose. The next part of the survey asks the respondent to compare 

how he or she was doing in many areas of life before the disaster with how he or she is doing at 

the time of survey completion. The survey concludes with a section on basic demographics, 

language, and disability status. The form can be found in the CCP Toolkit at 

www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings. 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 21

Why is this necessary?

The survey performs three important functions for the CCP. First, it provides information about 

service quality from the viewpoint of the recipient. The CCP is a short-term intervention, where 

an encounter could be just 15 minutes or could occur multiple times and is considered relatively 

anonymous. Therefore, the survey questions were informed by findings that disaster behavioral 

health services should be evaluated on the basis of their credibility, acceptability, accessibility, 

and confidentiality, among other characteristics.

Second, the survey provides the program with excellent information about the experiences and 

reactions of people they aim to serve in their outreach. It is one of the most important clinical 

records of the program. This information could lead to program adjustments to meet previously 

unrecognized needs. 

Third, the survey helps planners learn about factors that influence perceptions of service quality. 

For example, are highly distressed individuals more or less positive about services than are less 

distressed individuals? Are members of different ethnic groups equally likely to report that they 

were treated with respect and sensitivity?

Who should complete the survey?

The survey is given to a sample of people for whom individual or family crisis counseling 

services were provided (that is, not for people who received services documented only on a 

Weekly Tally Sheet or who participated in group counseling/public education activities). It is 

given only to adults. The reading level is approximately fifth to sixth grade (based on the FleschKincaid assessment).

When is the survey done?

The survey is implemented at six and 12 months after the disaster. The CCP will identify a one- or

two-week period at each time (six and 12 months after the disaster), and all people who receive 

individual or family contacts are asked to complete an anonymous survey. In larger programs, 

different areas can be surveyed in consecutive weeks. The number of survey respondents is 

compared to the total number of eligible adults served in individual crisis counseling or group 

crisis counseling (not including public education groups) during that period to estimate the 

response rate.

How is the survey done?

During the selected period for data collection, all people who receive individual or family 

contacts are given a packet containing a cover letter signed by the program director, the survey, a 

black ink pen, and a stamped pre-addressed envelope for returning the survey. The packets are to 

be distributed to supervisors one week in advance of dissemination, and supervisors give crisis 

counselors a set of packets to distribute. A template for the cover letter and handouts for 

counselor training can be found in the CCP Toolkit at www.samhsa.gov/dtac/ccp-data-formstrainings. The CCP should contact the SAMHSA Disaster Technical Assistance Center (DTAC) 

to ask that they generate a link to the survey, which can be used by data entry staff to enter forms 

that have been received.
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 22

Alternatively, the survey link generated by SAMHSA DTAC can be distributed to participants in 

qualifying encounters or used by crisis counselors on the mobile app to allow participants to 

complete the survey immediately after an encounter.

What is the counselor’s role?

Crisis counselors distribute the survey and other materials. The importance of the crisis 

counselor’s attitude in this process cannot be overstated. The counselor must view this survey as 

an opportunity for recipients to tell the program (anonymously) how they feel about the services 

and their reactions. Counselors might introduce the survey by saying that, this week, program 

leaders are making a special effort to learn about the needs of the community and how 

counselors are helping to meet those needs. Counselors might further note that the survey is short 

and should take only a few minutes of the person’s time. Counselors who view this as a burden 

will convey that attitude to potential respondents. It is essential that this form be given to each 

service recipient who should get it. Only then will the information be meaningful and useful to 

the program. 

How are counselors protected?

Some crisis counselors could understandably be concerned that the survey might be used to 

evaluate their own performance rather than that of the program as a whole. Additionally, some 

crisis counselors work in areas where survivors might be angry in general and could get lower 

ratings through no fault of their own. Although the questions refer to “the counselor,” the survey 

does not name a particular crisis counselor. The data are examined only in groupings, defined by 

county or respondent characteristics. 

Are satisfaction data biased?

The positive bias in “consumer satisfaction” measures is well documented. People tend to answer 

in high ranges on consumer satisfaction surveys even when they have not improved. The tool 

addresses this bias by using a wide response format that allows room for variation. Recipients 

answer each question about their experience of the CCP on a five-point scale, where 1 is the 

worst rating and 5 is the best rating. Over time, the pooled data have provided norms that can be 

used to interpret data from new programs.

Relevant Research

 Schaeffer, N.C. & Dykema, J. (2011). Questions for surveys: Current trends and future

directions. Public Opinion Quarterly, 75(5), 909-961. Doi:10.1093/poq/nfr048.

 Tourangeau, R., Couper, M.P. & Conrad, F. (2004). Spacing, position, and order:

Interpretive heuristics for visual features of survey questions. Public Opinion Quarterly,

68(3), 368-393. Doi:10.1093/poq/nfh035

 Tourangeau, R., Couper, M.P. & Conrad, F. (2007). Color, labels, and interpretive heuristics 

for response scales. Public Opinion Quarterly, 71(1), 91-112.

Doi:10.1093/poq/nfl046
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 23

Service Provider Feedback Form

What is the purpose of this form?

Crisis counselors are the essential link between the program and the consumer. Crisis counselors 

and their supervisors are in a unique position to judge the quality of the services being provided 

and the extent to which they match the needs of the community. The Service Provider Feedback 

Form yields a standardized assessment of providers’ opinions and reactions to their work.

Who is included?

This form is intended for crisis counselors who provide direct, face-to-face services to disaster 

survivors. This also includes their immediate supervisors (team leaders) who guide the crisis 

counselors’ work. These workers are included regardless of the number of hours they work each 

week. This assessment tool is administered only to workers who have performed these functions 

for a month or more. Staff who perform only administrative, clerical, or evaluation functions are 

not surveyed. 

What’s in the Service Provider Feedback Form?

The form has several parts. The first section asks staff to evaluate the usefulness of the CCP 

training they have completed. The next section asks staff to evaluate the support, supervision, 

and opportunities for growth provided by the work. This section also asks about the 

appropriateness of the workload and the adequacy of resources and tools available, and for the 

provider’s evaluation of the services provided by the CCP. The section that follows is composed 

of five questions about stress. These questions examine whether the work or the provider’s 

reaction to it has caused problems in other areas of his or her life. The form requires management 

to include a phone number outside of the chain of supervision that counselors can call to receive 

assistance if they are feeling especially stressed. The next section includes questions about the 

experiences counselors have had completing CCP data collection forms on using the PDF 

version or in the mobile app. A subsequent section collects information on how much the crisis 

counselor has worked for the CCP, as well as demographic information. The form concludes 

with a place to add comments. The form can be found in the CCP Toolkit at 

www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings. 

When and how is it done?

These data are collected anonymously from crisis counselors and their supervisors at roughly six 

and 12 months after the disaster. These time-points typically occur within the RSP. The form is 

administered online in coordination with SAMHSA DTAC. Paper administration is acceptable 

only when online administration is not possible. For paper administration, supervisors distribute 

a packet containing a cover letter, the form, and a black ink pen to each crisis counselor, together 

with a stamped return envelope addressed to an external evaluator. Although the forms may be 

handed out during a staff meeting, they should be completed later so that crisis counselors do not 

feel pressured to participate. Two weeks before the form is distributed, the program director 

should send an email or other notice (for example, a letter) to all crisis counselors and team 

leaders informing them of the forthcoming form and explaining why it is important to complete 

it. Two weeks after the form is distributed, the program director should send a thank-you and 
CCP Data Collection Forms and Instructions (Version 4.2) Section 3 

2022 Guide for Evaluating Your CCP (Version 4.2) | 24

reminder email or letter to all counselors and team leaders. Templates for form administration 

are located in the CCP Toolkit at www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms-trainings. 

How are counselors protected?

Some counselors could understandably be concerned that supervisors or program directors could 

figure out who they are even though the form is completed anonymously. However, SAMHSA 

DTAC takes several precautions to guarantee anonymity to all CCP counselors. For those 

completing the online form, no personal identification is required, and all data are kept in a 

secure database and only reported at the aggregate level. For paper administration, the completed 

form is mailed to an external evaluator so that it does not go through local program management. 

Regardless of the number of workers, provider forms are collected for the cumulative national 

database. Detailed results are shared with local program management only if the number of 

workers is greater than 15. Smaller programs receive less specific results. When results are 

shared, they are shown only in aggregations large enough to ensure that individual crisis 

counselors or small groups of counselors are not identifiable. 

Relevant Research

 Bellamy, N. D., Wang, M. Q., McGee, L. A., Liu, J. S. & Robinson, M. E. (2019). Crisiscounselor perceptions of job training, stress, and satisfaction during disaster recovery. 

Psychological Trauma: Theory, Research, Practice, and Policy, 11(1), 19.

 Creamer, T. L. & Liddle, B. J. (2005). Secondary traumatic stress among disaster mental 

health workers responding to the September 11 attacks. Journal of Traumatic Stress, 18(1), 

89-96. doi:10.1002/jts.20008.

 Deighton, R. M., Gurris, N. & Traue, H. (2007). Factors affecting burnout and compassion 

fatigue in psychotherapists treating torture survivors: Is the therapist’s attitude to working 

through trauma relevant? Journal of Traumatic Stress, 20(1), 63-75. doi:10.1002/jts.20180.

 Devilly, G. J., Wright, R. & Varker, T. (2009). Vicarious trauma, secondary traumatic stress 

or simply burnout? Effect of trauma therapy on mental health professionals. Australian and 

New Zealand Journal of Psychiatry, 43, 373-385.

doi:10.1080/00048670902721079.

 Rossi, A., Cetrano, G., Pertile, R., Rabbi, L., Donisi, V., Grigoletti, L. & Amaddeo,

F. (2012). Burnout, compassion fatigue, and compassion satisfaction among staff in

community-based mental health services. Psychiatry Research. Advance online publication. 

doi:10.1016/j.psychres.2012.07.029.