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
Form and Instruction Child Assessment and Referral Tool
Group Encounter Log Modified 3300 165 0 Form and Instruction Group Encounter Log
Individual/Family Crisis Counseling Servies Encounter Log Modified 117600 9408 0 Form Individual/Family Encounter Log
Form Group Encounter Log
Form Weekly Tally Sheet
Form Adult Assessment and Referral Tool
Form Child/YOuth Assessment and Referral Tool
Form Service Provider Feedback Form
Participant Feedback Form Modified 1000 250 0 Form and Instruction Participant_Feedback_Form
Form and Instruction Participant Feedback Form
Service Provider Feedback Form Modified 100 41 0 Form and Instruction Service Provider Feedback Form
Weekly Tally Sheet Modified 31200 4860 0 Form and Instruction Weekly Tally Sheet
Total burden requested under this ICR: 159062 16206 0  
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