
Place a home phone number on the form, and the
work number of the client if the client is working.

The person will either:
a. be a minor and have a parent or guardian, in which
case you circle or underline “parent” on the form and
write in the name of the parent, or
b. be an adult with a spouse, in which case you underline
or circle “spouse” on the form and write in the name of
the spouse, or
c. be neither of these, in which case you write N/A in big
letters on that line.
Why do you think it is important for
Human Service Professionals/Agencies
to document initial inquires/new referral
forms?
If the person is employed:
place the name of the employer on that line.
If the person is not employed, place N/A on
that line.
 If the person is in school:
place the name of the school (complete with
what kind of school—college, elementary
school, high school) on that line. If the person
is not in school, place N/A on that line.

“Who referred
you to our
services?”

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 self-referrals 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.

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?
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.
 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.



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.

Under “Verification Sent,” write “Yes”
and the date. The date you use here is
the date you send out the verification
form, usually the same day on which you
take the phone inquiry.
After a person has inquired about
services from your agency, it is important
to bring the person in for a more
thorough history and evaluation of the
problem, if the person is seeking services.
You will set up an appointment for the
caller on the phone at the time of the
call or soon after you hang up.
 The next step is to send a letter verifying
or confirming this appointment.




Keep the reasons from being too complicated
- Do not create clients who are experiencing
a psychiatric emergency.
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.
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.





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.
Does the client sound animated or depressed?
Does the client speak normally or seem
pressured or vague?
Does the client seem to want to get help or use
the services?
Did the client tell you how he or
she is feeling?




On the Verification form, be sure that the date you
send it out is the same date you said you sent it out
on your New Referral or Inquiry form.
Be sure to address the client by name.
Fill in the date, time, staff, and location of the
interview. The date is the date you listed under
“disposition” on the inquiry form. You can decide
on a time. The staff person will be you. The
interview will take place at the Wildwood Center.
Sign your name. Your signature should line up
precisely under “Sincerely” and over “Case
Manager.” Do not sign out to the right.
WHAT DO YOU THINK IS
YOUR ROLE IN THE FIRST
INTERVIEW?

Chap 15: The First Interview
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.






Look at the intake material.
Check past agency records.
Look at past medical history.
Keep in mind the material was collected by
others who saw the client under very
different circumstances.
Make sure your office is a comfortable
place in which to confide in another
person.
Go out to the waiting room to meet the client.
 Introduce yourself, using your full name.
 Make a mental note of your first impressions of the client.
 Make a mental note of the clients reactions to you and
the situation
 Show an interest in what the client has to say.
 If asked, give your credentials.
 Point out respectfully, if asked personal questions, that
the interview is about the client, not about you.
 Describe the agency and its purpose.
 Make sure payment arrangements have been explained.
 Make sure confidentiality limitations and policies have
been explained.




It is alright to take notes. Note-taking ensures
accuracy
Allow clients to tell the story in their own way.
Encourage the client to talk about their issues
by using open questions and reflective
listening.
EXAMPLES:
So the last 8 months have really been difficult
with your mother.
Tell me a little bit about what’s been
happening with her.
Avoid judging clients who may have
different values or lifestyles from your own.
 To seek more clarification use open
questions.

EXAMPLE:
Can you tell me more about your
sister’s comments that evening?

Refrain from using why questions which may
sound like prying or ask for a level of
understanding the client does not have.
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 problem. This is generally
what brought the client to the agency.
 The extent to which the problem has interfered with
the client’s ability to function.
 The support system the client has or does not have.
 What the client is expecting as a
result of coming to the agency.

Clients or their guardians should
participate in the planning
 Ask people what it is they would like from
your agency
 Often they will not know what services
are available or what they need
 Explore together what treatment or
service options there are for the client









Ask clients if they have any questions they want to
ask you.
With the client define the problem in language they
understand.
Verify what the client is expecting.
Tell the client what will happen next.
Give the client an appointment card if there is to be
a next appointment.
Rise at the end of the interview to indicate the
interview is complete.
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 where
other clients can overhear you.
A social history is:
 A description and history of the
presenting problem (the problem that
brought the client into the agency).
 Background information on the person’s
life.
Unemployment
Homelessness
 The worker’s impressions and
Domestic Violence
Lack of
recommendations.
Transportation
Basic Skills Deficient
Offender
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
Medical history
 Legal history
 Social and recreational
interests
 Religious activities
 Client successes and
strengths
 Client resources
Your assessment
 Your impressions
 Your recommendations

It is sometimes difficult for clients to open up to a
stranger.
 Use open questions to soften the interview.
 All closed questions can sound like a grilling.
 You will use a few closed questions to get information
that you need
EXAMPLE:
How many days a week do you work?

Ask questions with respect and a genuine interest in
the client.
EXAMPLE:
Tell me about the work you do.

Refrain from using vague descriptions or general
information.
 Make the information you put in the social history
specific.
 Look at the history you wrote to see where you would
have questions if you were reading it for the first time.
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.

When agencies have limited funding to
serve the client only a short amount of
time a brief social history is necessary.
 A brief social history has three parts:

1. Presenting problem
2. Background to the presenting
problem
3. Your impressions and
recommendations
Presenting problem - describe why the
client is here.
 Background to the presenting problem give additional information on the
presenting problem, the history of it, and
some relevant background information
on the client.
 Impressions and recommendations write your thoughts about the client and
what the client needs.

Assessment forms
 These are used when agencies need a lot of detailed
information
 The form is an outline of what is important.
 You need to stop and ask open questions as you go
through the form. Talk with the client in addition to
asking the questions.
Taking social histories on the computer:
 Computers are used so that the history does not have
to be typed after you have written it.
 It is essential that you have enough space to write
what is important and that you be able to see and
fully engage the client.
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.
Impressions
Next state your impressions. Write about these areas if
they are relevant:
functioning
affect
vegetative functions
insight
motivation to change
motivation to accept help
EXAMPLE:
Marie is somewhat guarded with a flat affect. She
shows some insight into her problem and indicated
some motivation to change the situation both at
home and at school.
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 achievement.

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


Category headings on the same page as the
information that follows the heading.
Bold all your subheadings.
Staple the pages of the history together.
All social histories must be typed.
Social histories should be placed in the same location
in every chart or record.
Be sure the history indicates “taken by” or “prepared
by” with your name and credentials.
Don’t state as fact things the client told you but you
do not know firsthand. Say, “according to client’ or
“the client stated”.