FOR OFFICIAL T]SE ONLY FAIRCHILD A&FRC STATEMENT OF UNDERSTANDING Date
Status:
LAST 4 SSN
Name
AD RET GUARD RESERVE CIV SINGLE MARRIED
Grade/Rank Service
PRP:
YA{
MIL to MIL Other Duty Phone
Unit/Squadron
Address
Mailing (if different) Home, Cell Phoneie-mail Family Members: Spouse name Children/DOB Address during Deployment (if different) Reason for visit
:
DEPLOY/TDY Est. Departure:
Est. Return:
Where are you going:
Welcome to the Airman & Family Readiness Center (A&FRC). We respect your right to privacy. However, we do not have complete privileged communication. Applicable laws and USAF policy require staff to contact proper authorities about statements made or information disclosed by a client that pertains to violation or possible violation of the PRP (AFl 36-2104), the Family Advocacy Program (AFI40-301) or admission of a crime in violation of the UCMJ, federal or state law. Examples of Disclosurethat must be reported to proper authorities include but are not limited to: Communicating a threat to injure or harm yourself or others, abuse/neglect of a child/spouse or other dependent, military members involved in the unauthorized use of firearms/dangerous weapons; crimes against the government. If your chain of command made an appointment for you, they may be notified you did keep the appointment and general feedback may be provided. When someone is seen as a self-referral, squadron personnel are not routinely notified. Routine Uses of information gathered is stored electronically and used for family trends and funding that impact the mission. Disclosure is voluntary.
Privacy Act Statement: Authority: l0 U.S.C. 8013, EO 9391 and 13478. Purpose: Client demographics required for client service delivery, trend analysis, and future family program planning. Information is secure and stored electronically.
@?lh'ilk /SIGNEDII Christopher Marble, Chief, A&FRC, Fairchild AFB, WA DSN: 651-2246 COMM: 5A9-247 -2246
My signature certifies I have read and understand the above information.
MEMBER SIGNATURE
DATE
FAMILY ME,MBER SIGNATURE
DATE
STAFF'INITIALS
Nov 2010
FOR OFFICIAL USE OI{LY Date:
Sponsor's Last 4:
PRI :Name:
Please answer this brief inventory; it helps us understand your overall personal readiness and adjustment to military life. lnstructions: Based on the past week please rate how well things are going by placing a hash mark on the 0-10 scales below, with 10 as the best possible rating. Your consultant will use your answers to clarifu your goals for coming to the Airman and Family Readiness Center.
OVERALL ADJUSTMENT TO MILITARY LIFE (Understand & support the military lifestyle
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RELOCATIOI{/MOVING (Ability to move when required)
ADJUSTMENT TO COMMUNITY (Ability to find on/off-base information, services, events & activities, etc...)
DEPLOYMENT READINESS (Ability to support short-notice deployments, awareness of available support for loved ones, etc...)
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FINANCIAL READINESS & financial obligations met, savings, investments & retirement' etc...)
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MILITARY/WORK E NVIRONMENT (Work environment/relationships OPSTEMPO/pace of work)
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PERSONAL RELATIONSHIPS (Family, FriendS, & loved ones etc...)
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RETENTION (Intention to continue military career past current commitment) Ol,
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TRANSITION TO CIVILIAN LIFE (Prepared for separation/retirement, aware of benefits & entitlements, etc.)
fl The information accessed through this application must be protected IAW AFI 33-332 and DoD Regulation 5400.1 1; Privacy Act 1974 [Public Law 93-579] as Amended Applies.
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