Form 1 Brief Contact

BCP/TLP Brief Service Report

NEORHYMIS v2.1 - BRIEF SERVICE CONTACT REPORT

Expiration date 09/30/2013

OMB Control No 0970-0123

This instrument collects information regarding brief service contacts by Family and Youth Services Bureau (FYSB)-funded Basic Center or TLP grantee agency staff.

Brief service contacts are defined as program staff contacts with either of the following:

(1) a young person who has not been formally admitted to the program at the time of the contact

(2) other individuals associated with a young person who has not been formally admitted to the program at the time of the contact.

A brief service contact might include, for example, conducting a 45-minute phone consultation with a young person who is seeking assistance and then providing him or her referral to an appropriate program. Brief contacts may also comprise one-time interactions with parents, friends, and professionals to link a youth to appropriate services outside the FYSB agency.

Youth to whom Basic Center or Transitional Living Program staff provide informal, unstructured or partial day (drop-in type services lasting fewer than 6 hours and/or do not involve overnight stays, should be entered in this Brief Service Contact Record. Youth who are a prescribed course of structured, FYSB-funded services (such as family counseling or other in-home prevention services), but are not staying at the Basic Center, should be entered as a non-resident and fully recorded in NEORHYMIS.

Brief service contacts regarding youth who are entering or already are in the FYSB Program should not be documented here. Street contacts by FYSB-funded Street Outreach Program grantee staff with young people living on the street (or youth coming to a Street Outreach Program drop-in center) should be reported on the Street Outreach Program Contact Record. Agencies have the option to create more than one "Brief Service Contact" record during the reporting period, provided that each Start and End date fall within the current period being reported upon. Example: During the October/March timeframe, a new Brief Service Contact record may be created by week, by month, etc.

Full and accurate reporting of these brief service contacts is important because it helps to inform the U.S. Congress and funding sources about brief services provided by grantees to link young people with appropriate services, often with preventive results.

Center ID: [ display only ]

Updated By: [ display only ]

Updated Date: [ display only ]

Reporting Period Covered

Start Date ______________________ (mm/dd/yyyy)

End Date _______________________ (mm/dd/yyyy)

1. Brief Contact Type (select one of the following):

1	Call
2	Drop-In
3	Other

2. Individual Contacting the Agency (select one of the following):

1	Youth himself/herself
2	Parent/legal guardian of young person
3	Relative or friend of young person
4	Other adult or youth calling on behalf of young person
5	Partner/spouse of young person
6	Youth professional calling on behalf of young person
7	Other professional calling on behalf of young person (such as a police officer, social worker, or school personnel)

3. Contacts:

Please enter the total number for the specified contract type and individual contacting the agency for brief contact services during the reporting period.

4. System referrals: If referral was made to one of the “system” services below, please indicate which one. Otherwise, select “Not Applicable”.

NOTE: This referral check-off is to provide a rough headcount of current foster care, juvenile justice or mental health "system" youth (who are not included in the FYSB treatment population) whom you refer to or treat with system-funded services after they present themselves at the FYSB shelter.

1	Foster Care/Child Welfare/ Independent Living System
2	Juvenile Justice System
3	Mental Health System
4	Other System
5	Not Applicable