Magellan MFLC Duty to Warn Report Form

Counselor Name: / Date/Time of Event:
Supervisor Name: / Date/Time Supervisor Notified:
Date Report Made: / State in Which Report Made: / Installation: / Unit (Guard or Reserve only):
Service Member Branch:
USA
USAF
USMC
USN / Military Status of Service Member:
Active
National Guard
Reserve
DoD Civilian Expeditionary Workforce
Civilian (ineligible) / Type of Report (Primary Reason):
Mandated
Duty to Warn
Both / Type of Report (Secondary Reason, if applicable):
Mandated
Duty to Warn
Both
Primary Issue Related to DTW/MR (Select only one):
Harm to self
Harm to others
Domestic Abuse
Child abuse/neglect
Sexual assault
Abuse/neglect of a vulnerable adult
Illegal Activity
Personnel Reliability Program / Secondary Issue Related to DTW/MR:
Harm to self
Harm to others
Domestic Abuse
Child abuse/neglect
Sexual assault
Abuse/neglect of a vulnerable adult
Illegal Activity
Personnel Reliability Program
Summary of Event:
Actions Taken:
Agencies/Titles of Individuals to Whom Report Made:
FAP Notified: Yes No If “No”, explain below:

INSTRUCTIONS:

Counselors:

  • Complete form by filling in all applicable fields.
  • Do not indicate family/service member name anywhere on form.
  • Fax or email to your supervisor immediately upon completion.
  • Enter “date/time” using military time as follows: mmddyy/hhmm.
  • Ensure there is a corresponding activity form submitted with DTW selected AND all referrals included.

Supervisors:

  • Review with your manager.
  • Forward completed form within 24 hours via fax or email to your manager AND the QAIT Director.

DEFINITIONS:

  • Mandated Report (MR) A report made by a mandated reporter (counselor, teacher, childcare provider, law enforcement personnel or other persons) required by DoD policy, state or federal law, who on the basis of their training, have reasonable cause to suspect an issue for which a mandated report is required. Any Provider who sees a PRP service member or family member is mandated to report the meeting to the service member’s Command. Failure by mandated professionals to initiate a Mandated Report can result in professional and personal penalties.
  • Duty to Warn (DTW) Duty to Warn refers to the responsibility of a Provider to inform third parties or authorities if a Participant poses a threat to himself or herself or to another identifiable individual. The responsibilities of Duty to Warn were further extended to include the review of previous records that might include a history of violent behavior. A Duty to Warn gives the Provider the right to breach confidentiality if a Participant poses a threat to another person. Duty to Warn protects Providers from prosecution from breach of confidentiality if they have reasonable suspicion that the Participant might be a danger to himself or others.

Version 5 – modified 29-JAN-2015