Unit 5: Meeting Clients' Needs and Assessing
Their Strengths – Craig Owens (Prof C or Craig)
Unit 5 “To-Do” List
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Project
Family violence Website and PBS Rape video
(Please note this is an emotional video)
Discussions on first interview & crisis interview
Seminar Agenda
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Applying the learning
Documentation, documentation, documentation
The Unit 5 Project
Questions
Applying the
Learning…
What was the
most significant
thing you
learned in last
week’s
discussion
about reflective
listening or
disarming
anger?
Fundamentals of Case Management Practice:
Skills for the Human Services, Third Edition
(Select slides chosen by Craig Owens
from author’s PPT‘ chapters 14,15, and 16 – some have been
modified for this lecture)
By
Nancy Summers (Adapted by Craig Owens, KU)
Published by
Brooks Cole
Cengage Learning
2009
STEPS FOR FILLING OUT THE NEW
REFERRAL OR INQUIRY FORM II
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The client will either be:
a. a self-referral, meaning the person found out about your
agency through the phone book or a friend and called in on his own.
If that is the case, write “self” on that line. Most calls are selfreferrals or
b, referred by a doctor or other professional. In that case, place
that person’s name on the line. You are asking the client, “Who
referred you to our services?” Answers might be Dr. Graham Smith
or Attorney William Burns.
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Under the section marked “Chief Complaint,” always tell why the
person called today. Do not say the person called today because
her husband is abusing her. The husband may be abusing her, but
what made her go to the phone today?
STEPS FOR FILLING OUT THE NEW
REFERRAL OR INQUIRY FORM III
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Under “Previous Treatment,” keep the notes brief—just note when,
where (and with whom if you know that), and for what. Keep from
being too wordy in this section.
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The intake is “taken by” you. This is the first place your name is to
appear on this form! Put the date of the intake next to your name.
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Under “Disposition,” note the name of the person to whom you refer
the new client for intake and the date of the intake appointment. In
many settings, the person who handles the phone inquiries is not
the same person who sees the clients when they come in for their
first appointments. For training purposes, we will assume that you
will be doing both the phone inquiry and the client intake, in which
case you would write your own name, along with the date of the
intake appointment, on that line.
CAPTURING HIGHLIGHTS OF THE CHIEF
COMPLAINT (Reason for visit)
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Keep the reasons from being too complicated - Do not create
clients who are experiencing a psychiatric emergency.
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Be very specific - Give specific facts of the clients problem (when,
where, how often, what is going on currently). Do not use vague
general descriptions.
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Keep the reasons for the call brief - On this form give only the
immediate details. Save the detailed background information for the
social history you take from the client in person.
EVALUATING THE CLIENT’S MOTIVATION
AND MOOD
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Always end your chief complaint section with a sentence
or two about how the client sounded on the phone or
how the client seemed to you.
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Does the client sound animated or depressed?
Does the client speak normally or seemed pressured
or vague?
Does the client seem to want to get help or use the
services?
Did the client tell you how he is feeling?
YOUR ROLE IN THE FIRST INTERVIEW
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Listen and convey and accurate understanding of clients’
perceptions about themselves and their problems. This is done
using reflective listening.
Formulate a professional understanding of what it is the client is
experiencing and what this person will need while being served by
your agency.
Strive to establish rapport with clients so that they feel comfortable
with you and with your agency.
What can we do to prepare for
the first interview before the
client arrives or before we
arrive at the client’s home?
PREPARING FOR THE FIRST INTERVIEW
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Look at the intake material; special needs or cultural considerations?
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Check past agency records or transferred records if available.
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Look at past mental health or medical history.
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Keep in mind the material was collected by others who saw the
client under very different circumstances.
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Make sure your meeting area is a comfortable and welcoming and
private place in which to confide in another person. Consider where
the client will sit and where you will sit.
What are some
of the initial
things we might
want to do when
we are meeting a
client for the first
time?
MEETING THE CLIENT
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Go out to the waiting room to meet the client.
Introduce yourself, full name and how you prefer to be addressed.
Make a mental note your first impressions of the client.
Make a mental note of the clients reactions to you and the situation.
Ask the client how they prefer to be addressed?
Be genuinely interest in what the client has to say.
Describe the agency and its purpose.
Make sure payment arrangements have been explained.
Make sure confidentiality limitations and policies have been
explained – this is where it is very important to explain
mandatory reporting and confidentiality breaks for safety
reasons.
WHAT TO DO AS CLIENTS DESCRIBE
THEIR ISSUES
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It is alright to take notes but we should explain why and the types
of things we will be writing down.
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Allow clients to tell the story in their own way. Try and use mostly
reflective listening skills initially to ensure the client feels heard.
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Encourage the client to talk about their issues by using open
questions.
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Can you provide an example of a reflective listening response
to a client who seems very nervous?
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What would be an example of an open-ended question in this
situation?
WHAT INFORMATION TO COLLECT
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Seek to understand why the client is here now as opposed to last
week or last month. What happened to bring the client in now.
Document:
 The client’s presenting issue. This is generally what brought them in
to the agency.
 The extent to which the problem has or has not interfered with the
client’s ability to function.
 Client strengths as well as any possible risk areas (safety)
 The support system the client has or does not have.
 What the client is expecting as a result of coming to the agency.
WRAPPING UP
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Ask how this first meeting went and if they have any questions.
Verify what they hope to accomplish and what their goals are.
Tell them what to expect next in this process.
Give the client an appointment card if there is to be a next
appointment or information on any referrals they agree to.
Offer to escort the client back to the check-out desk.
Do not allow clients to leave if you think they are considering
harming themselves or someone else.
After clients leave do not talk about them except in the privacy of
your supervisor’s office if you need to consult on something.
I like to close each client session by asking them what they
found helpful, if anything, and what they want to work on next
time we meet.
Fundamentals of Case Management Practice:
Skills for the Human Services, Third Edition
Chapter Sixteen
Social Histories and Assessment Forms – Modifications by
Craig Owens solely for the use of this seminar.
By
Nancy Summers
Published by
Brooks Cole
Cengage Learning
2009
WHAT IS A SOCIAL HISTORY?
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What is the purpose of completing a social
history with a client?
WHAT IS A SOCIAL HISTORY?
A social history:
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It provides us with a description and history of the presenting
problem (the problem that brought the client into the agency).
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It provides background information on the person’s life.
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It provides an opportunity to document the worker’s initial
impressions and recommendations.
What do you think are some of the
categories of information we capture in a
social history?
Categories and Layout of a typical Social
History (Often called Psychosocial
Assessment)
Presenting problem
 Description and history of the
presenting problem
Background information
 Family of origin
 Birth and childhood
 Marriages and significant
relationships
 Current living arrangements
 Education
 Military service
 Employment history
 Barriers to health or dignity
Medical history
 Mental health history
 Legal history
 Social and recreational
interests
 Religious activities
 Client successes and
strengths
 Client resources
Your assessment
 Your impressions
 Your recommendations
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HOW TO ASK WHAT YOU NEED TO KNOW
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It is sometimes difficult for clients to open up to a stranger.
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Use open questions to soften the interview.
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Using all closed questions can sound like a grilling.
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You will use a few closed questions to get information that you need
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What is an example of an open question you might use at this
point?
How about a closed question that would be appropriate at this
stage?
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CAPTURING DETAILS
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Refrain from using vague descriptions or general information.
EXAMPLE:
Poor example:
Alice is divorced.
Better example:
Alice was married in 1992 and was divorced in 2008, following
her husband’s incarceration for armed robbery.
SOCIAL HISTORIES IN OTHER SETTINGS
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When agencies have limited funding to serve the client only a short
amount of time a brief social history is necessary.
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A brief social history has three parts:
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Presenting problem - describe why the client is here.
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Background to the presenting problem - give additional information on the
presenting problem, the history of it, and some relevant background information
on the client.
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Impressions and recommendations - write your thoughts about the client and
what the client needs.
WRITING IMPRESSIONS
First sentence
 Begin with the same comprehensive sentence you used to open
your social history.
EXAMPLE:
Marie is a 13 year old girl living with her single mother and currently
addicted to crack.
Next two or three sentences
 Write two or three sentences to describe the client’s situation.
EXAMPLE:
She is currently not attending school and her mother indicates she
cannot manage her at present. The girl’s father is not in the picture
and mother works 2 jobs to support the daughter and herself.
WRITING IMPRESSIONS
Impressions
Next state what you observe about the client’s affect (facial
expressions), speech, and motivation for change.
EXAMPLE:
Marie appears somewhat guarded with a flat affect. She speaks in a
quiet steady tone, which matches her lack of affect. She shows
some insight into her problem and indicates some motivation to
change the situation both at home and at school.
WRITING RECOMMENDATIONS
Recommendations
Finally write your recommendations and say what they are for.
EXAMPLE:
Recommend 3 weeks intensive inpatient treatment for detox,
followed by NA meetings 90 meetings/ 90 days for support in
remaining clean, family and individual counseling to develop better
family relationships and Marie’s self-esteem. Recommend Marie
return to school at the end of inpatient treatment to maintain her
academic status and progress.
Unit 5 Project – Helping Blair
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This week, you will write a five-page research paper on a rape case
study. Using information from the textbook and one article from
the Kaplan Library on domestic violence, specifically rape,
make sure to address:
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the signs and symptoms of what the client is going through
the physical exam with a male doctor
how you will interview the client and the interview skills you will use
ethical issues you may encounter
the legal issues the client will face
future interventions for the client
Tip: Do not get so caught up in writing about the effects of rape; that you forget
to address the last four bullet points in detail. The first bullet; signs and
symptoms should not go over 1 to 2 pages of your 5 page paper or you will not
have enough detail on the other parts of this assignment.
Questions?
Have a great
week,
remember to
breathe...