1. OT/PT Dept Awaiting Service to Active Contact family to set appointment On the day you first try to call the family, discharge from AWAITING SERVICE, re-admit to ACTIVE Casenote in ACTIVE while you try to contact the family, and until you are finished the assessment If there is no intake on file, go to page 4, then come back here Determine how frequently you plan to see the child If < every 3 months, then discharge from ACTIVE, (you will be cued to enter a discharge Needs Assessment). & re-admit to MONITORING If > every 3 months, leave in ACTIVE Complete Initial Needs Assessment within 90 days (if you did not see the child, skip this) Write report within 3 months of initial contact Provide Intervention. Casenote all contact within three working days Create goals with family. Review at least every 6 months Update Needs Assessment at least every 6 months. Write full progress report at least every 12 months Start HERE If unable to contact, call referral source. If still unable to contact after writing letter, discharge. Let other OSNS programs know you were unable to contact. Check with other OSNS programs about their involvement with the family If we have consent for outside agencies (eg IDP), check with them about their involvement with the family Page 1 Jan 2010 See Page 4 See Page 6 See Page 3 See Page 5 Discharge from services

2. OT/PT Dept Awaiting Service to Consultation Contact family to set appointment On the day you first contact the family, discharge from AWAITING SERVICE, re-admit to CONSULTATION Casenote in CONSULT until you are finished your involvement If there is no intake on file, go to page 5, then come back here Complete Initial Needs Assessment within 90 days (if you did not see the child, or discharged right away, skip this) If no concerns, discharge from services and let other team members know Start HERE If unable to contact, call referral source. If still unable to contact after writing letter, discharge. Let other OSNS programs know you were unable to contact. Check with other OSNS programs about their involvement with the family If we have consent for outside agencies (eg IDP), check with them about their involvement with the family See Page 4 See Page 6 See Page 3 Page 2 Jan 2010 Guidelines & Paperwork Important to explain to parents that this is not service. Child is still on waitlist. We want them to understand that true therapy service is much more detailed and comprehensive and intensive. We are just trying to do the best we can with our waitlist. Use 1-3 visits to complete your screening/ consultation Leave child in CONSULT when you are finished your involvement Chart your detailed observations in CONSULT case notes. Provide family with: Short letter/report summarizing observations and recommendations Home programming suggestions Who to call with questions Provide a list of groups we run that their child might be appropriate for (including Summer Program) Update consent forms if things have changed since intake. Generally don’t use standardized assessments – just a screening opportunity. If you really don’t feel you see the whole picture, you can use an assessment to help. These children can be seen by TSW if that seems appropriate. Make Internal Referral See Page 5

3. OT/PT Dept HOMES – Discharge & Re-admit Discharge Choose ‘discharge’ from File Folder drop down menu From the HOMES casenote page (of the current OT/PT program of the client) From the HOMES Main page Complete the fields in blue (date, discharge date etc) For moving between OT/PT programs: 6.Next Step Program 7.N/A Choose ‘Discharge, Closure, or Transfer Report’ under “Case And Outcome Management” Type in client name and click ‘Search’. Choose correct program. Complete the fields in blue (date, discharge date etc) For moving between OT/PT programs: 6.Next Step Program 7.N/A Re-Admit From the HOMES Main page Choose ‘Readmit a Client & Student’ under “Case Demographics” Click on the drop down envelope to the right of 1. Client/Student. Type in client name and click ‘Search’. Choose correct client. Complete the fields in blue 3. Choose the OT/PT program you are admitting the child to 5. Select the MOST RECENT ‘Intake and Case management’ Program 7. Do NOT “Check All” Page 3 Jan 2010

4. OT/PT Dept HOMES - Needs Assessments (NA) Open client in HOMES under the program he is currently enrolled in. In the ‘File Folder’ tab, choose Initial Assessment Rate the needs appropriately, then SAVE. If child has just transferred from another program this initial NA should be the same as the D/C NA in previous program Open client in HOMES under the program he is currently enrolled in. In the ‘File Folder’ tab, choose ‘Progress and Updated Service Plan’ PRINT: click Reports tab at the top. Then choose “Program Needs Assessment”. Right click to print First time Needs Assessment in this HOMES program Repeat Needs Assessment within same program Rate the needs appropriately, then SAVE. PRINT: click Reports tab at the top. Then choose “Interim Outcome Reports”. Choose “Pre to Interim Post”. Right click to print. Discharge Needs Assessment (either to move to new program or to discharge altogether) When you choose “Discharge” from the file folder tab, you will be cued to enter a discharge NA Rate the needs appropriately then SAVE PRINT: click Reports tab at the top. Then choose “Outcome Reports”. Choose “Pre to Post Program Needs Assessment”. Right click to print What if I want to add a new Need when it is identified during one of the Repeat NAs? Go back to the Initial NA in the CURRENT OT/PT program Without changing the date, enter the new need in this NA and rate it as you see it today It will then appear on all the subsequent NAs until today’s. That’s okay. It is not counted in outcomes until it changes. When you want to re-rate it during the next NA, it will be there to record a change Page 4 Jan 2010

5. OT/PT Dept HOMES – Discharge Forever When discharging a child from OT/PT Department (not just between programs) Complete final needs assessment If applicable 2) will automatically come up. Enter 1-2 sentences to state reason for discharge. Click “Save and continue to list” On “Needs and Issues Addressed” page, choose “Program Measures” (top left side) then “Program Report Comments” Choose “Add All” on bottom right side under check boxes 1), 2), 3), on left side are now blue. Choose 1) and enter 1-2 sentences to summarize your services. Then click “Save and continue to list” Choose “Reports” from top line Click “case reports” Click “Discharge Report (Standard Version)” Report will be on the screen. Right click and print. Sign and include in your discharge file. Page 5 Jan 2010

6. OT/PT Dept Seeing a Child When No Intake is on File Once the paperwork is done, put the intake form, and the two consents in the Receptionist’s box. Don’t worry about getting all the paperwork done on the first visit. You can interact with the child and develop a rapport with him. Keep the paperwork for the end of the visit, or even the next one. If there is no intake on file, it is your job to complete one with the family. This happens most often with the infants who are referred. Most of one visit will be dedicated to sharing info about OSNS with the family, gathering intake information, and getting consents signed On your first visit, take: Intake form Consent to Release Information Consent to Service Agreement Parent Handbook Brochure In the Main file, on the pink sheet at the front, fill in the bottom three lines (parent handbook, intake and consents) and initial. If you feel the child is older, or the family circumstances would benefit from having the Family Resource Worker complete the intake, feel free to make that request. Young infants don’t usually require a lot of time to gather info, but older ones (or complicated ones) do and then the FRW can be called upon. Now go back to Page 1 When completing forms with parents/guardians, be sure to Review complaint process Explain parent rights Read each bullet of Consent to Service agreement Page 6 Jan 2010