DA Form 5897 "Army Community Service (Acs) Client Case Record"

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1. CASE NUMBER
ARMY COMMUNITY SERVICE (ACS) CLIENT CASE RECORD
For use of this form, see AR 608-1; the proponent agency is ACSIM.
PRIVACY ACT STATEMENT
AUTHORITY:
5 USC Section 301, Departmental Regulations; 10 USC Section 3013, Secretary of the Army; Army Regulation 608-1, Army
Community Service Center.
PRINCIPAL PURPOSE:
To provide appropriate background information needed for Army Community Service personnel to help individuals seeking
assistance.
ROUTINE USES:
None.
DISCLOSURE:
SECTION A - GENERAL INFORMATION
2. NAME OF CLIENT (Last, first, MI)
3. DATE OF INITIAL
4. DATE CASE CLOSED
5. TOTAL NUMBER
APPOINTMENT(YYYYMMDD)
(YYYYMMDD)
OF SESSIONS
6. TYPE OF CASE (Check one)
7. STATUS OF CLIENT (Check one)
8. BRANCH OF
SERVICE
ACTIVE
RESERVE
RETIRED
INDIVIDUAL
COUPLE
FAMILY
FAMILY MEMBER
CIVILIAN
SECTION B - PERSONAL DATA
9. SEX
10. MARITAL STATUS (Check appropriate box)
MALE
MARRIED
DIVORCED
WIDOW/WIDOWER
DUAL MILITARY CAREER
FEMALE
SINGLE
SEPARATED
SINGLE PARENT W/CUSTODY
UNKNOWN
11. CLIENT'S ADDRESS AND E-MAIL
14. WORK PHONE
12. EMPLOYER/ASSIGNMENT
13. HOME PHONE
ADDRESS (Street, City, State, and ZIP Code)
AND FAX PHONE
a. Sponsor
b. Family Member
15. EDUCATION (Number of years, degree(s))
16. CLIENT'S AGE
17. DATE MARRIED (YYYYMMDD) 18. TIMES MARRIED
a. Sponsor
b. Family Member
19a. NAME OF CHILDREN
19b. CHILDREN'S AGES
19c. SCHOOL OR LOCATION
20a. OTHER HOUSEHOLD MEMBERS
20b. AGE
20c. RELATIONSHIP
DA FORM 5897, MAY 1999
DA FORM 5897-R, JUL 90, IS OBSOLETE.
Page 1 of 2
APD LC v1.01ES
1. CASE NUMBER
ARMY COMMUNITY SERVICE (ACS) CLIENT CASE RECORD
For use of this form, see AR 608-1; the proponent agency is ACSIM.
PRIVACY ACT STATEMENT
AUTHORITY:
5 USC Section 301, Departmental Regulations; 10 USC Section 3013, Secretary of the Army; Army Regulation 608-1, Army
Community Service Center.
PRINCIPAL PURPOSE:
To provide appropriate background information needed for Army Community Service personnel to help individuals seeking
assistance.
ROUTINE USES:
None.
DISCLOSURE:
SECTION A - GENERAL INFORMATION
2. NAME OF CLIENT (Last, first, MI)
3. DATE OF INITIAL
4. DATE CASE CLOSED
5. TOTAL NUMBER
APPOINTMENT(YYYYMMDD)
(YYYYMMDD)
OF SESSIONS
6. TYPE OF CASE (Check one)
7. STATUS OF CLIENT (Check one)
8. BRANCH OF
SERVICE
ACTIVE
RESERVE
RETIRED
INDIVIDUAL
COUPLE
FAMILY
FAMILY MEMBER
CIVILIAN
SECTION B - PERSONAL DATA
9. SEX
10. MARITAL STATUS (Check appropriate box)
MALE
MARRIED
DIVORCED
WIDOW/WIDOWER
DUAL MILITARY CAREER
FEMALE
SINGLE
SEPARATED
SINGLE PARENT W/CUSTODY
UNKNOWN
11. CLIENT'S ADDRESS AND E-MAIL
14. WORK PHONE
12. EMPLOYER/ASSIGNMENT
13. HOME PHONE
ADDRESS (Street, City, State, and ZIP Code)
AND FAX PHONE
a. Sponsor
b. Family Member
15. EDUCATION (Number of years, degree(s))
16. CLIENT'S AGE
17. DATE MARRIED (YYYYMMDD) 18. TIMES MARRIED
a. Sponsor
b. Family Member
19a. NAME OF CHILDREN
19b. CHILDREN'S AGES
19c. SCHOOL OR LOCATION
20a. OTHER HOUSEHOLD MEMBERS
20b. AGE
20c. RELATIONSHIP
DA FORM 5897, MAY 1999
DA FORM 5897-R, JUL 90, IS OBSOLETE.
Page 1 of 2
APD LC v1.01ES
SECTION C - SERVICE DATA
21a. SPOUSE'S NAME (Last, First, MI)
21b. MILITARY ADDRESS
21c. RANK/GRADE
22. SOURCE OF REFERRAL (Check appropriate boxes)
SELF
CIVILIAN AGENCY
MEDICAL (Military)
CHAPLAIN
LEGAL
COMMAND
MILITARY
VOLUNTEER
23. REQUEST FOR SERVICE
24. PRESENTING PROBLEM
25. ASSESSMENT
26. TREATMENT PLAN
27. SUMMARY OF SERVICE
28. PRIMARY SERVICE
29. REFERRALS TO
30. FAMILY ADVOCACY INFORMATION
a.
PERSONAL COUNSELING
a.
LEGAL
a.
SPOUSE ABUSE
b.
MARRIAGE COUNSELING
b.
CHAPLAIN
b.
CHILD ABUSE
c.
FAMILY COUNSELING
c.
RED CROSS
c.
CHILD NEGLECT
d.
FAMILY/CHILD DEVELOPMENT
d.
HOUSING
d.
INCEST
e.
EXCEPTIONAL FAMILIES
e.
CHILD CARE CENTER
e.
RAPE
f.
CAREER INFORMATION
f.
MEDICAL
f.
SEXUAL ASSAULT
g.
FINANCIAL COUNSELING
g.
VA
g.
DRUG ABUSE
h.
EMPLOYMENT COUNSELING
h.
SOCIAL SECURITY
h.
ALCOHOL ABUSE
i.
RELOCATION COUNSELING
i.
OTHER (Specify)
i.
OTHER (Specify)
j.
OTHER
k.
SUPPLEMENTAL SERVICES (Specify)
31. BOOKS/PAMPHLETS RECOMMENDED
32. CLASSES/WORKSHOPS RECOMMENDED
33. FOLLOWUP
34a. ACS STAFF MEMBER'S SIGNATURE
34b. DATE (YYYYMMDD)
35a. SUPERVISOR'S SIGNATURE
35b. DATE (YYYYMMDD)
DA FORM 5897, MAY 1999
Page 2 of 2
APD LC v1.01ES
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