Behavioral Health Program – Tracker Behavioral Health Program - Tracker Behavioral Health Program - Tracker Name * SelectDr. Hugo Catalan Jr.Tice MerriweatherDr. Melissa Ryan O’KeefeVera Rodriguez Activity Date * Total Time Spent * 000102030405060708091011121314151617181920212223 : 0030 Task * SelectPersonal ContactCritical IncidentPresentation / Station VisitTrainingConferenceAdministrative TasksContinuing EducationMeeting Type of Contact SelectTherapy SessionConsultationAssessment Therapy Session Contact Made With * SelectCivilian MemberSworn MemberFamily of Civilian MemberFamily of Sworn MemberRetiredOther Age of Person Contacted * Select3-67-1112-1718-2930-3940-4950+ Rank or Position of Person Contacted * SelectAOCaptainChief OfficerCivilianEngineerFirefighterInspectorParamedicShipmate / DiverPilotOther Gender Identity * SelectMaleFemaleTransgenderNon-BinaryOther Sexual Orientation * SelectBisexualGayHeterosexualLesbianOtherUnknown Ethnicity * SelectAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Paciffic IslanderWhiteOther Presenting Issue * SelectAddictionBehavioral Concerns at WorkCritical IncidentCumulative Stress ReactionsDepressive SymptomsExpressions of Hopelessness/HelplessnessFamily of Origin StressesFeelings of AnxietyGrief and LossParenting Issues / Child - Related StressesPost Traumatic Stress ResponsesRelationship ConflictRetirement Concerns Referral Source * SelectCenter Team MemberCritical Incident Response Indicated Need for Individual ContactFollow Up / AddictionsFollow Up after Critical IncidentSupervisor ReferralReferral Made by Family Member or FriendReturn from Military DeploymentSelf ReferralReferral Made By UFLAC Board MemberOther Type of Treatment * SelectIndividual SessionCouples SessionFamily Session Session Type * SelectQuestion TypeIn-PersonTelephonicVirtual Critical Incident Contact Type * SelectIndividualGroup of Less Than 5Group of 5-10Group of 10 or More Report Type * SelectInitialFollow UpAdditional Follow Up Type of Outreach SelectTelephonicIn Person Type of Stress Injury * SelectLine of Duty DeathDeath of Family MemberDeath of ChildBody RecoveryStressful Incident OperationMayday SurvivalClose Call with Injuries to CrewGrotesque InjuriesInjured MemberMember SuicideDisasterSerious Traffic Accident Involving First ResponderOther Type of Action Taken * SelectClinician OutreachCrisis Management BriefingCritical Incident Stress DebriefingCritical Incident Stress DefusingOn Scene SupportPeer-Support Outreach Location of Outreach * SelectBy TelephoneAt Fire StationAt Incident SceneOther Presentation / Station Visit Requesting Presentation Group * Topic Covered * Approximate Number of Participants * Training Subject Training Attended * Conference Subject Training Attended * Consultation Consultation Provided to * SelectBattalion ChiefCaptainDepartment MemberOutside AgencyMHP (Mental Health Provider)Peer Support MemberOther Continuing Education Subject * Meeting Subject * Type of the Meeting SelectQuestion TypeConference CallWebinar / ZoomIn Person Submit If you are human, leave this field blank.
