APPENDIX
H
FAMILY
MEMBER CONTACT RECORD
SPOUSE/CALLER DATA SERVICEMEMBER DATA
NAME: NAME:
PHONE NO. (HOME)(NOW): RANK:
ADDRESS: UNIT:
CALLER MOOD:
HAPPY CALM ABUSIVE SAD/DEPRESSED HYSTERICAL
IF SAD/DEPRESSED - ARE YOUR CHILDREN WITH YOU NOW?
HAVE YOU THOUGHT ABOUT HURTING YOURSELF?
HAVE YOU BEEN USING ALCOHOL? DRUGS?
HOW RECENTLY?
HOW CAN WE HELP YOU?
WHAT DO YOU WANT DONE?
WAS THE CALLER REFERRED TO ANOTHER ARMY AGENCY? YES NO
IF YES, WHERE?
FOLLOW-UP NEEDED? WHEN?
Table
of Contents
Appendix
G: Flow Chart for Helping Distressed Spouses
Appendix
I: Family Assistance Questionnaire
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