Steps in the real world…
The first step in a client getting treatment is an intake (aka initial interview)
In many community mental health clinics the intake is completed by a “screener” or “triage specialist” who is a specialized case manager
The screener would:
Gather information about the client
Start the referral process
Psychiatrist, therapist, case manager
Make a preliminary diagnosis
Make sure that necessary paperwork is completed
The client does not see the screener again after the intake
The First Interview
The purpose of the first interview is to establish the following basic information about the person:
Strengths, including external support systems, talents. Successes, capabilities, and positive attitudes and events that the person defines as a success
Weaknesses, including gaps in the external support system, lack of experience or information, negative attitudes, and events the person defines as failures
Current problems that caused this individual to seek help now
Potential problems
A sense of who this person is
Your Role
You have three tasks to accomplish in this first interview.
Listen and convey an accurate understanding of clients’ perceptions about themselves and their problems.
You formulate a professional understanding of what it is the individual is experiencing and what this person will need while being served by your agency.
You strive to establish rapport with clients so that they feel comfortable with you and your agency.
The Client’s Understanding
In most cases, people have recognized the need for help; but in a few cases, they may feel that they do not to be in your agency.
The courts mandate that some individuals seek help or face jail or permanent removal of their children.
In situations in which clients feel forced to come to your agency, you may encounter hostility.
In either case, you must indicate that you have heard all their concerns about being there.
You can convey this through your ability to reflect back how clients are feeling about being in the agency.
Even when people believe they need help, they may not be clear that the current situation is painful, but unclear about how to describe
The Interview
The Intake Interview
Intake interviews are conducted to determine the nature of the individual’s problems and to decide whether the psychologist or agency has the ability to help with such problems
Usually 45-90 minutes
Information sought in intake:
Demographics
Family and educational background
Focus on the presenting problem
Past psychological, medical history
GOAL: obtain as much information as possible in order to determine the next step of treatment
Developing a Service Plan
Service plan= treatment plan, goal plans, or care plans
Contains broad, general goals for the case management unit to follow with regard to a particular person
Highly individualized, no two treatment plans should look the same
Should cover all the needs of the client based on the evaluation, intake process
Should be a collaborative process
Client should know exactly what is on their treatment plan
Client should be involved in the creation of plan
If the client is a minor or unable to take care of themselves, family members can be added to the process
Preparing for Meetings
As a case manager, prepare yourself for a life of meetings
Meetings with clients, meetings with agencies, meetings with treatment teams, etc
Come prepared!
Always have with you:
Calendar
Tentative service plan
Human service directory
Documentation & Recording
The importance of documentation
Emergency, liability
Fee-for-service, reimbursement
Productivity
Collaboration with other team members
“If it isn’t documented, it didn’t happen.”
Writing Contact Notes
Your notes in your client’s chart should always include:
The focus/reason for the contact
And how you contacted them!
Your assessment based on a concise summary of behavior, appearance, and affect
Any resolution that takes place
The reason for the next contact or follow-up that will occur
SOAP note
