1. Fundamentals of Case Management Practice: Skills for the Human Services, Third Edition Chapter Fourteen Documenting Initial Inquiries By Nancy Summers Published by Brooks Cole Cengage Learning 2009

2. STEPS FOR FILLING OUT THE NEW REFERRAL OR INQUIRY FORM I 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. 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.

3. STEPS FOR FILLING OUT THE NEW REFERRAL OR INQUIRY FORM II 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?

4. STEPS FOR FILLING OUT THE NEW REFERRAL OR INQUIRY FORM III 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.

5. STEPS FOR FILLING OUT THE NEW REFERRAL OR INQUIRY FORM IV 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.

6. CAPTURING HIGHLIGHTS OF THE CHIEF COMPLAINT 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.

7. EVALUATING THE CLIENT’S MOTIVATION AND MOOD 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 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?

8. STEPS FOR FILLING OUT THE VERIFICATION OF APPOINTMENT FORM 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.

9. WHAT IS A SOCIAL HISTORY 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. The worker’s impressions and recommendations.

10. Layout of the social history: the categories to cover 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

11. HOW TO ASK WHAT YOU NEED TO KNOW 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.

12. CAPTURING DETAILS 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.

13. SOCIAL HISTORIES IN OTHER SETTINGS 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.

14. OTHER WAYS TO TAKE SOCIAL HISTORIES 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 important that you have enough space to write what is important and that you be able to see and fully engage the client.

15. WRITING IMPRESSIONS AND RECOMMENDATIONS 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.

16. WRITING IMPRESSIONS Impressions Next state your impressions. Write about these areas if they are relevant: functioningaffectvegetative functions insightmotivation to changemotivation 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.

17. 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 achievement.

18. NOTES ON ASSEMBLING GOOD HISTORIES 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”.