Wildwood case management unit new referral or inquiry

CHAPTER 14: Documenting Initial Inquiries Introduction In many agencies, phone inquiries are logged on the computer and kept on file there. The “New Referral or Inquiry” form used in this text contains the kind of information the individual would be asked to provide during an initial call to the agency, particularly if the person were asking for an appointment. Learning to gather this information properly is important to ensure that the person’s situation is handled well from the beginning. This first form, for our purposes, is extremely basic. The form is used to take information from people calling on the phone to obtain services. Some agencies do more extensive phone intakes. Others ask a few questions on the phone and have the client fill in forms in the waiting room before ever seeing a case manager for the first time. This particular form was designed to give you practice in noting general information about the client and practice in capturing succinctly the presenting problem. You are to ascertain what the problem is, in brief, and set up an intake appointment in which the caller will be seen in person for a more in-depth history and evaluation. Remember to use all the communication skills you have learned in previous chapters to make the person feel at ease while describing the problem. Asking for help is difficult, but it is less so if the phone worker is empathic and accepting. PLEASE NOTE You cannot accept a case and fill out this entire form on the word of another person. The other person can refer the client to your agency, but the client must call in order for the intake to be valid. Exceptions to this rule exist when (1) the person is incapable of calling due to a mental health emergency (other forms are used for this situation); (2) the person needing services is a child (a parent or guardian can call for the child); (3) the caller is very infirm, has an intellectual disability, or is a frail older person (a family member or friend can call for that person); or (4) the person needs an interpreter to communicate. Walk-ins Some case management units report that many people do not call but come to the office in person. Usually, this same form, or one like it, would be filled out by reception personnel. In some places a very similar form is given to the client to fill out in the waiting room. Generally walk-ins, whenever possible are seen that same day. People who feel a need to come in seeking help usually feel their situation is urgent. Seeing the person for a full intake can prevent an emergency room visit later or a crisis in the person’s life that might escalate if there were no intervention. For our purposes we will use a phone intake form, but it is a good idea to be aware that people do not always use the phone and may come in when they feel they need help. Guidelines for Filling Out Forms The following guidelines apply to filling out all forms: 1. Use black ink. Never use a pencil to fill out a form. 2. Do not use correction liquid on forms; it is not permissible. 3. Be sure to sign and date any form you complete or note you write. 4. N/A (Not Applicable) is generally used where there is no answer or the question does not apply to the client. Steps for Filling Out the New Referral or Inquiry Form A form for phone inquiries is found in the Appendix C. It is titled “New Referral or Inquiry.” Use the following step-by-step process when filling out this form. Make a photocopy of the blank form in the Appendix C at the back of this book, and fill it out by following these steps: Step 1. Place the person’s name, sex, date of birth, and address at the top of the form in the spaces provided. Step 2. Place a home phone number on the form, and the work number of the client if the client is working. Step 3. The designated client 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. Step 4. 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. Step 5. 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. Step 6. The individual 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 or her 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 caller, “Who referred you to our services?” Answers might be Dr. Graham Smith or Attorney William Burns. When writing a doctor’s name be sure to indicate if it is an MD or a PhD. Step 7. 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? Here are some reasons people might give for calling today: • Today the person decided she cannot go on. • This morning, his employer insisted he get help. • What happened last night was the last straw. • She saw a medical doctor within the last 48 hours who told her she needs counseling. • He just had a fight with his spouse and is afraid of what he might do. • He just hit his child. • This morning he started to think about going back on drugs again. • She thinks she will hit her child and has called for help to stop herself. In filling out the “Chief Complaint” section, capture why the person called on this date and not on some other day. Begin this section with “Client (or the person’s name) called today because …” Capturing the Highlights of the Chief Complaint You have a small space and can use very few sentences to describe why the person called today and not some other day. In thinking about what the caller has told you about why he or she called, choose the most important points. The details will be noted when you take the social history. Here are some examples: John Haulik called today because his employer requested he seek help for drug problem (crack). In last 2 weeks, he has missed or been late to work every day. Sleeping on the job and cited for safety violations. Client sounded distressed and anxious to begin treatment. Jane Wilson called today after a serious fight with her husband involving physical abuse. Jane states husband has been verbally abusive in past, but not physically. Client is hospitalized and looking for alternative safe living arrangements upon discharge. Client sounds depressed, but cooperative. Following are some guidelines to keep in mind for capturing the highlights: • Keep the reasons from being too complicated. Do not make these first cases psychiatric emergency situations that need either immediate attention or a commitment. In other words, in this first exercise, do not create clients who are hearing voices, are contemplating suicide, have made a suicide attempt, or are a danger to others. • Be very specific. Do not use general descriptions such as “her husband beats her” or “she lives with an alcoholic” or “he has been having a hard time at work.” Tell when the last beating was, what the most recent problem with the alcoholic husband was, and what the most recent problem was for the client at work. • Keep the reason for the call brief. Do not include a lot of background information, as that will be acquired when you do the social history at the time of the evaluation. Give just enough background information to let the next worker know the context of the client’s problem. For example: • Angelica called today because she was severely beaten by her husband on Tuesday during an argument over dinner. Client was hospitalized and is seeking alternative shelter. There is a history of domestic violence, which the client feels has worsened in the last 9 months. • Horace called today because his employer warned him that without evidence of treatment for problems with alcohol, employment may be terminated or suspended. He admits to drinking while on the job today. There is a pattern of binge drinking followed by missed work and problems with coworkers. Steps for Completing the New Referral or Inquiry Form The following steps complete the process described in the previous section, which ended with Step 7. Step 8. 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. For example: Incorrect: Susan saw Dr. Piper at the Waldenham Clinic, 432 Muench Street. She started to see him in June of 2013 after her first son was born and continued to see him for 6 months. He was treating her for postpartum depression. Correct: Seen in June of 2013 for 6 months by Dr. Piper, Waldenham Clinic, for postpartum depression. Step 9. 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. Step 10. 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. Step 11. 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. Figure 14.1 shows a new referral or inquiry form that has been filled out correctly. Look at the form to see how the worker filled in each element. FIGURE 14.1: Sample new referral or inquiry form 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. Evaluating the Client’s Motivation and Mood Complete your note with a single sentence that indicates how the caller seemed to you. For example, you can mention how the client sounded. Did the caller seem depressed, glad to have reached you, relieved to be getting help, guilty over what has happened? Did the person seem eager to engage in services, skeptical that you can help, cynical about complying with forced treatment, or cooperative? Here are some examples of sentences that might summarize how the caller seemed to the phone worker: • Curt expressed a desire to begin treatment immediately and seemed angry. • Marci seemed depressed by the circumstances but motivated to follow through with services. • Pete expressed skepticism that anyone could help him but seemed motivated to seek help. • Aisha was tearful and seemed depressed during the interview. • Harold seemed agitated by these recent developments and somewhat unwilling to follow agency procedure. Steps for Preparing the Verification of Appointment Form Not all agencies use verification letters. Those that do, do so to confirm for people the appointments that were made with them for an initial intake in the office. In this way, the agency hopes to cut down on the number of missed appointments and the number of hours reserved for people that are not used by them because they fail to show up. (Blank copies of the forms referred to in this section can be found in the Appendix C.) Today many agencies have more clients than they can see easily. Long waiting lists are the result. An agency cannot afford to waste an hour on a person who does not come in for a scheduled appointment. Although it may give the individual worker a much-needed break and time to catch up on paperwork, it is an hour for which the agency will not always be reimbursed because no services are given. For that reason, some agencies send out a verification letter to remind people of the appointments that are reserved for them. Following is a step-by-step procedure for filling out the verification form. A blank verification form can be found in the Appendix C at the back of this book. Make a photocopy of that form and follow these steps to fill it out: 1. 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. 2. Be sure to address the person by name. 3. 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. 4. Sign your name. Your signature should line up precisely under “Sincerely” and over “Case manager.” Do not sign out to the right. Figure 14.2 contains a sample verification of appointment form with all the information added. Look at the form to see how the worker addressed each element. FIGURE 14.2: Sample verification of appointment form The next step in the process is when the person actually comes to the agency for a more thorough evaluation of his or her situation. This is sometimes called an intake appointment. In this chapter, we have practiced phone intakes; in Chapter 15, we will turn to the first appointment and examine how to prepare to meet the individual for the first time. Summary Taking an intake from a person on the phone requires two important skills. The first is skillful communication, something you have been working on previously. Using the skills you have acquired, you will be able to draw the caller out and learn the reasons for the call. In addition, you will need good observation skills. Your task, during this first phone call, is to assess the needs of the person calling and assess the degree of distress the person is experiencing. On your “New Referral or Inquiry” form, you will need to be able to document not only what the person shared with you on the phone but also the way that person sounded, how motivated the person seemed, whether the person’s conversation with you seemed reasonable, and how distressed the individual seemed to be. As you practice your communication skills, begin also to practice listening to the tone of voice and the underlying emotions the client may not express directly. Exercises These exercises can also be filled out online at CengageBrain.com. Exercises I: Intake of a Middle-Aged Adult Instructions: Using the blank form in the Appendix C titled “New Referral or Inquiry,” develop a client intake. You may use any problem that would ordinarily come to the attention of a social service agency. Your client should be an adult, at this point, calling on his or her own to seek services. In developing your client and your client’s problem, read the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) and look at books and articles on specific problems (such as domestic violence, alcoholism, divorce, depression, addiction). Look at the chapters in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), for information on how your client might be feeling and what issues or problems the client might be facing when he or she makes the first call to your agency. If time permits, do several adult intakes with each client having a different reason for calling. Practice sending a verification letter to your hypothetical client. Exercises II: Intake of a Child Instructions: Using the blank form in the Appendix C titled “New Referral or Inquiry,” develop a client intake for a child, a person under 16 years of age. In this case, a parent or guardian would be calling on behalf of the child. A doctor, a school counselor, or a teacher may have referred the parents to you, or the parents may have felt they needed help and sought your services without a referral. Typical issues confronting children are problems with school, behavioral problems, and adjustment problems to events such as divorce or the death of a parent. In developing your client and your client’s problem, read the DSM 5 and look at books and articles on specific problems common to children. Look at chapters (particularly those on children’s mental health and on developmental disabilities) in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), for information on how your client and your client’s parents might be feeling and what issues or problems the client’s parents might be facing when they make the first call to your agency. Practice sending a verification letter to your hypothetical client. Exercises III: Intake of an Infirm, Older Person Instructions: Using the blank form in the Appendix C titled “New Referral or Inquiry,” develop a client intake for an older person, a person over 80 years of age. In this case, a child or close friend or neighbor would be calling on behalf of the client. A doctor may have referred the caller to you, or the caller may have felt the client needed help and sought your services without a referral. Typical issues confronting frail, older adults are problems with self-care, independent living problems, untreated medical conditions, malnutrition, and depression and anxiety. In developing your client and your client’s problem, read the DSM 5 and look at books and articles on specific problems common to older people. Look at the chapter in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), for information on how your client and the concerned caller might be feeling and what issues or problems the caller might be facing when making the first call to your agency. Practice sending a verification letter to your hypothetical client.

CHAPTER 14:

Documenting Initial Inquiries Introduction In many agencies, phone inquiries are

logged on the computer and kept on file there. The “New Referral or Inquiry” form used in this text

contains the kind of information the individual would be asked

to provide during an initial call to the

agency, particularly if the person were asking for an appointment. Learning to gather this information

properly is important to ensure that the person’s situation is handled well from the beginning. This

first form,

for our purposes, is extremely basic. The form is used to take information from people

calling on the phone to obtain services. Some agencies do more extensive phone intakes. Others

ask a few questions on the phone and have the client fill in forms in the

waiting room before ever

seeing a case manager for the first time. This particular form was designed to give you practice in

noting general information about the client and practice in capturing succinctly the presenting

problem. You are to ascertain what

the problem is, in brief, and set up an intake appointment in

which the caller will be seen in person for a more in

-

depth history and evaluation. Remember to use

all the communication skills you have learned in previous chapters to make the person feel at

ease

while describing the problem. Asking for help is difficult, but it is less so if the phone worker is

empathic and accepting. PLEASE NOTE You cannot accept a case and fill out this entire form on

the word of another person. The other person can refer

the client to your agency, but the client must

call in order for the intake to be valid. Exceptions to this rule exist when (1) the person is incapable

of calling due to a mental health emergency (other forms are used for this situation); (2) the person

ne

eding services is a child (a parent or guardian can call for the child); (3) the caller is very infirm,

has an intellectual disability, or is a frail older person (a family member or friend can call for that

person); or (4) the person needs an interpreter

to communicate. Walk

-

ins Some case management

units report that many people do not call but come to the office in person. Usually, this same form, or

one like it, would be filled out by reception personnel. In some places a very similar form is given to

th

e client to fill out in the waiting room. Generally walk

-

ins, whenever possible are seen that same

day. People who feel a need to come in seeking help usually feel their situation is urgent. Seeing the

person for a full intake can prevent an emergency room

visit later or a crisis in the person’s life that

might escalate if there were no intervention. For our purposes we will use a phone intake form, but it

is a good idea to be aware that people do not always use the phone and may come in when they

feel they

need help. Guidelines for Filling Out Forms The following guidelines apply to filling out all

forms: 1. Use black ink. Never use a pencil to fill out a form. 2. Do not use correction liquid on forms;

it is not permissible. 3. Be sure to sign and date any

form you complete or note you write. 4. N/A

(Not Applicable) is generally used where there is no answer or the question does not apply to the

client. Steps for Filling Out the New Referral or Inquiry Form A form for phone inquiries is found in

the Appendix

C. It is titled “New Referral or Inquiry.” Use the following step

-

by

-

step process when

filling out this form. Make a photocopy of the blank form in the Appendix C at the back of this book,

and fill it out by following these steps: Step 1. Place the person

’s name, sex, date of birth, and

address at the top of the form in the spaces provided. Step 2. Place a home phone number on the

form, and the work number of the client if the client is working. Step 3. The designated client 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. Step 4. 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. Step 5. 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.

Step 6. The individual will either be: a. A self

-

referral, meaning the person found ou

t about your

agency through the phone book or a friend and called in on his or her 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 caller, “Who referred you to our

CHAPTER 14: Documenting Initial Inquiries Introduction In many agencies, phone inquiries are

logged on the computer and kept on file there. The “New Referral or Inquiry” form used in this text

contains the kind of information the individual would be asked to provide during an initial call to the

agency, particularly if the person were asking for an appointment. Learning to gather this information

properly is important to ensure that the person’s situation is handled well from the beginning. This

first form, for our purposes, is extremely basic. The form is used to take information from people

calling on the phone to obtain services. Some agencies do more extensive phone intakes. Others

ask a few questions on the phone and have the client fill in forms in the waiting room before ever

seeing a case manager for the first time. This particular form was designed to give you practice in

noting general information about the client and practice in capturing succinctly the presenting

problem. You are to ascertain what the problem is, in brief, and set up an intake appointment in

which the caller will be seen in person for a more in-depth history and evaluation. Remember to use

all the communication skills you have learned in previous chapters to make the person feel at ease

while describing the problem. Asking for help is difficult, but it is less so if the phone worker is

empathic and accepting. PLEASE NOTE You cannot accept a case and fill out this entire form on

the word of another person. The other person can refer the client to your agency, but the client must

call in order for the intake to be valid. Exceptions to this rule exist when (1) the person is incapable

of calling due to a mental health emergency (other forms are used for this situation); (2) the person

needing services is a child (a parent or guardian can call for the child); (3) the caller is very infirm,

has an intellectual disability, or is a frail older person (a family member or friend can call for that

person); or (4) the person needs an interpreter to communicate. Walk-ins Some case management

units report that many people do not call but come to the office in person. Usually, this same form, or

one like it, would be filled out by reception personnel. In some places a very similar form is given to

the client to fill out in the waiting room. Generally walk-ins, whenever possible are seen that same

day. People who feel a need to come in seeking help usually feel their situation is urgent. Seeing the

person for a full intake can prevent an emergency room visit later or a crisis in the person’s life that

might escalate if there were no intervention. For our purposes we will use a phone intake form, but it

is a good idea to be aware that people do not always use the phone and may come in when they

feel they need help. Guidelines for Filling Out Forms The following guidelines apply to filling out all

forms: 1. Use black ink. Never use a pencil to fill out a form. 2. Do not use correction liquid on forms;

it is not permissible. 3. Be sure to sign and date any form you complete or note you write. 4. N/A

(Not Applicable) is generally used where there is no answer or the question does not apply to the

client. Steps for Filling Out the New Referral or Inquiry Form A form for phone inquiries is found in

the Appendix C. It is titled “New Referral or Inquiry.” Use the following step-by-step process when

filling out this form. Make a photocopy of the blank form in the Appendix C at the back of this book,

and fill it out by following these steps: Step 1. Place the person’s name, sex, date of birth, and

address at the top of the form in the spaces provided. Step 2. Place a home phone number on the

form, and the work number of the client if the client is working. Step 3. The designated client 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. Step 4. 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. Step 5. 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.

Step 6. The individual 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 or her 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 caller, “Who referred you to our