Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Assessment and Referral Tool Modified 5862 1482 0 Form and Instruction Adult Assessment and Referral Tool Adult Assessment and Referral Tool
Form and Instruction Child Assessment and Referral Tool Child Assessment and Referral Tool
Group Encounter Log Modified 3300 165 0 Form and Instruction Group Encounter Log Group Encounter Log
Individual/Family Crisis Counseling Servies Encounter Log Modified 117600 9408 0 Form Individual/Family Encounter Log Individual/Family Encounter Log
Form Group Encounter Log Group Encounter Log
Form Weekly Tally Sheet Weekly Talkly Sheet
Form Adult Assessment and Referral Tool Adult Assessment and Referral Tool
Form Child/YOuth Assessment and Referral Tool Child/YOuth Assessment and Referral Tool
Form Service Provider Feedback Form Service Provider Feedback Form
Participant Feedback Form Modified 1000 250 0 Form and Instruction Participant_Feedback_Form Participant_Feedback_Form
Form and Instruction Participant Feedback Form Participant Feedback Form
Service Provider Feedback Form Modified 100 41 0 Form and Instruction Service Provider Feedback Form Service Provider Feedback Form
Weekly Tally Sheet Modified 31200 4860 0 Form and Instruction Weekly Tally Sheet Weekly Tally Sheet
Total burden requested under this ICR: 159062 16206 0  
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