Lesson 6: Intakes


Attention


Learning Outcomes

Upon completion of this lesson's material, students will be able to:

  • Demonstrate the ability to summarize and document a new referral's chief complaint.

Teaching

Mental health agencies may receive many calls each day from people seeking services. Sometimes the clients call directly and sometimes other service providers call. It is important to know what information to gather during the initial telephone call and how to document this information.  

This lesson will review the process of completing a typical intake/inquiry form and will address the skill of abbreviated and concise writing style.

Abbreviations and concise writing are key to ensure accurate records.

Review this document "Common Errors on the New Referral and Inquiry Form"

When you meet with a client you are listening for the informaiton they are telling you as well what they might not be telling you. You are watching the person's body language, the tone of voice, the pace of speech, and the types of words they are using. All of these pieces will help you make the best conclusions about what is going on, the person's emotional state, and what action you need to take. When the interaction is concluded you will then need to write a note about the interaction. This is the way that agencies are able to bill for the services offered. The note you write needs to justify the work you are doing and connect back to the client's treatment plan. When writting a summary statement you want to capture the highlights of the conversation and/or interaction. You want to write what you saw, the emotions present, what the issue(s) are and the plan you made to address them. The note is not a place to write the whole interaction verbatim, word for word. It is called a summary because you are summarizing the interaction. One of the key things to keep in mind is that a client always has the right to read his or her record at any time. You want to make sure that if your client read the note they would not be hurt or offended by what you wrote. Here is an example:

Marjorie and her mother have been fighting a lot lately so her mom asks you to come and do a home visit. During the visit they begin yelling at each other about the state of Marjorie's room, her grades in math and her new boyfriend. I could summarize this interaction a number of different ways.

A) I met for one hour with Marjorie and her mother Rosie in their home. They shared some concerns they had and we made a plan.

B) I met for one hour with Marjorie and her mother Rosie in their home. They started telling me about how they have been fighting 2 -3 days a week over the last few weeks. Once Rosie started talking about her frustration with Marjorie she had a hard time managing her anger and the had a fight about her room, her boyfriend and her grades. I worked to redirect mom to focus on one issue at a time and allowed Marjorie time to share her own thoughts and concerns about what has been going on in her life, including that she is very intimidated by her math teacher. Mom agreed to go to school to Marjorie in the next week to meet one on one with her math teacher. I will visit them again next Tuesday to see how things are going.

C) When I arrived at the home of Marjorie and Rosie it was not long before they started fighting in front of me. Rosie was yelling and being very demanding of Marjorie. Marjorie was being rude and disrespectful to Rosie. They went from one issue to another without resolving any of them. I told them they needed to pick one issue then we could problem solve. They picked her math grade and we made a plan for them to address this grade.

So what did you think? Which one best captures a summary of the interactive without a negative tone? Which one has enough detail? I tried to write B to be the best summary statement. Do you agree?

Now it's your turn. You are going to read the Abbreviating Statements document below and then you are going to write a summary for the two scenarios below.


Assessment

Welcome to Western Psychological & Counseling Services (WPCS)!

For this assessment you are going to play the part of a Case Manager at WPCS. You will locate a person to play the role of a "client". This can be a classmate or a friend or family member from your life. You will complete all of the following forms as if you were conducted a real intake at WPCS. You will record the intake meeting using your iPad video camera.

Keep track of this information and these forms as we will be using the information collected during the next few lessons.

Intake Forms to Complete

Lesson 6 Assignment

In this assignment you are going to submit the completed forms from the instructions above and ALSO submit a link to the video of you conducting the intake with your client.

You can submit multiple documents to the drop box.

Lesson 6 Quiz

Refer to the handout "Abbreviating Your Written Statements on Forms". Following the guidelines and suggestions from the handout, write a summary for each of the two scenarios.  The idea is to write a summary that you would use on a real form.  Be sure to include all of the pertinent information from the scenario in the summary for the client file.   

  1. Write your abbreviated summary for Client 1) The client called today because she says that her husband abused her last night. She thinks he drinks too much and that is what causes him to become abusive. She said he has been drinking a lot ever since they were married about 6 years ago. She has been in the hospital for a broken rib and leg at one time. That was some years ago. Her husband did that during one of their fights. She sounded scared and despondent. She says she is probably afraid to stay and afraid to leave to0. She wants some help with this.
  2. Write your abbreviated summary for Client 2) Mrs. Peters called today because she says she is depressed and needs help. She feels this has gone on too long and said she has been depressed since her husband died. She wants us to get her set up with a counselor or someone who can talk to her and also someone who can give her some medication for this. She sounded depressed on the phone. She cried and had trouble talking to me. Her life isn’t going well. Her husband died in March and then in July her dog died, so she feels her life isn’t going very well right now. She seems sad and not sure what to do.