Intake and Assessment Notes

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Humanities

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When working in Human Services, the intake process lays the foundation for building the helping relationship. The way intakes are done can vary from agency to agency. Many organizations will have specific forms or paperwork that the client will complete and go over with the Human Services professional. The information collected in the intake is only the beginning when it comes to learning about the client's needs.

Human Services professionals need to be mindful of how the intake discussion is communicated and documented. It is important to keep the language neutral and objective. The professional must not interject their own opinions or insights and the focus of the appointment must be on gathering information.

This week you will submit the Intake and Assessment Notes for your course project.

For this assignment you want to reread the client case study presented on the Course Project Introduction page located in Module 01.

Intake/Assessment Notes- For this submission, you will create an intake form that you would use in your initial meeting with the family. You will need to document the specific phrases and/or questions that you would use in order to obtain the information needed to work with the family. Be mindful of the language used with the client during the intake.

  • Intake Notes: Your intake notes should include questions or statements that collect information on the following as well as any additional information you feel is relevant:
    • Details related to each member of the family (age, sex, grade in school, etc.)
    • Family Structure
    • Employment status
    • Family history related to marital status, moving, work, etc
    • Background with Human Services
    • Current life stressors (work, financial difficulties, substance abuse, etc.)
    • Current needs the client has
  • Assessment Notes: Your assessment notes should document the information you know about the family from the referral. Although the assessment notes will more than likely not be seen by the client, it is important that the language used maintains professionalism and objectivity. You will want to include the following as well as any additional information you feel is relevant:
    • Note who made the referral
    • Identify the reasons for referral
    • Present the issues that you might address
    • Identify potential avenues of resources to explore

Unformatted Attachment Preview

Tony: I Just Don’t Know! Isabella Fraticelli, a practitioner in a home-based treatment program, received the following intake form for a new family to be seen next week. Intake information: The household consists of Cantrice Haywood (the mother, age 30), Anthony “Tony” Haywood (her son, age 12), Tawni Haywood (her daughter, age 9), and Terrence Clark (her son, age 3). This African American family lives in a townhouse apartment in a working class neighborhood. Terrence has significant physical challenges. He cannot walk, talk, or perform any ageappropriate tasks due to congenital disorders. He receives special services and daycare funded by the state. Terrence’s father, Charles, is a long-haul truck driver. Though he and Cantrice have not married, he lives in the household when he is not on the road. Tony and Tawni have the same biological father. Cantrice and her ex-husband have been divorced for approximately 5 years. Mr. Haywood lives in another state. He financially supports the children but usually only sees them a few times a year. Cantrice is a high school graduate and works approximately 40 hours per week in the food service industry. Because she is such a responsible, hardworking employee, her employer has been willing to work with her to allow her some flexibility to take care of Terrence’s medical problems. Reason for referral: Tony has been designated a Child in Need of Services (CHINS) with a history of aggression toward his mother, juvenile delinquency, and truancy. The judge was convinced to try intensive home-based services before removing Tony from the home. Tony has a diagnosis of Oppositional Defiant Disorder and has also been diagnosed with a learning disability. Case Vignette When Isabella entered the apartment, she met Tony, an average sized 12-year-old who didn’t meet her eyes. To Isabella, he seemed sullen and angry. He mumbled something when Cantrice introduced them and then he sat down and waited for the others to sit down and begin the session. ISABELLA: I am so glad to meet with all of you. (Turning to Tony) I want to make sure you understand why I am here. I know the judge talked to you about the seriousness of the charges that brought you before him last week. As you know, the judge thought you and your family might need some extra help so you could stay at home instead of going to another place. The judge has the power to order you to be taken out of your home, but he would really like you to be able to stay. I am here to work with all of you so you can stay with your family. We’ll be meeting twice a week for a while. To begin, I’d just like to hear what each of you sees as something that you might want to change in your family. CANTRICE: Well, first, I want to say I really want Tony to stay at home with his family, but not if he is going to cause a lot of trouble. I have to work to bring in money, and I am a worried about losing my job if I have to be at school or the police station because of Tony. ISABELLA: Tell me more about what you mean by trouble. CANTRICE: He gets in fights at school, fails some of his classes, cuts school, and hangs out on the street with the guys who have already dropped out of school. Then they call me at work to come in and meet with the principal about the trouble at school. ISABELLA: So you are really concerned about losing your job if you have to miss more work in order to help Tony. I think that is really understandable since you have a lot on your plate taking care of Terrence and keeping everything up in the house. (pause) How about you, Tony, would you like to see changes in the family? TONY: I don’t really care. ISABELLA: So you can’t think of anything you might like to be different, something that might make it easier for you to stay out of trouble at school. TONY: Just to be left alone to do what I want. I don’t want to be stuck at home taking care of Terrence. If “perfect” Tawni wants to waste her time, that’s okay. She’s a girl, so she likes to take care of babies. I don’t. CANTRICE: Well, you’re going to have to help because I can’t do any more than I am doing now. I mean, I have to work to earn the money we need, and I am really busy when I get home, too. Don’t you like to eat and have a clean house? TONY: I can take care of myself on the streets. I don’t need anything from you. CANTRICE: (turning to Isabella) See what it is like? I can’t handle any more problems than I already have. ISABELLA: I know this is a hard time for all of you. Let’s just take some time to talk, so maybe each person can understand what is troubling the others. This is a time to let everyone talk, and then we’ll see how we can make some decisions together. Tony, could you tell me more about what you mean by being left alone to do what you want? TONY: I don’t need anyone to take care of me. My friends get to hang out and do whatever they want to. No one makes them go to stupid old school! CANTRICE: Tell me more about your friends and what you like to do with them. TONY: They hang out and talk, play basketball, stuff like that. Some of them have a lot of money to spend, too. I want to be just like them. School didn’t help them much at all! ISABELLA: Even though we’ve been talking about how everyone might like the family to be, it seems like school is a big problem for Tony. Is that how you see it, Tony? TONY: School has always been a big problem for me. Maybe you can get me out of school? That would be so great! ISABELLA: I don’t think the law allows a 12-year-old to leave school permanently, but I think trying to improve your school situation would be something to work on that might be good for the whole family. I’m sure everyone in the family wants you to succeed in school and be happier. (Turning to Tawni) What about you, Tawni, what would you like to see different in the family? TAWNI: I don’t mind helping with Terrence. I like to do things with him. I really don’t want my mama to get upset so I try to help as much as I can. I guess I’d like to make it even easier for her. (Thinking a bit) Maybe Charles can be home more? ISABELLA: I’m glad you want to help. Right now, let’s talk about what we might like to see different. Later, we’ll work on some plans to make the things different you all talk about. (Turns to Cantrice) I know Charles isn’t here, but did you have a chance to talk about this session’s goal? CANTRICE: Well, just a little bit. He’s always so tired when he is here. I just hate to bother him. I know he likes to rest when he can. (She looks a little embarrassed.) He said to tell you he doesn’t want to have to do anything different, except when Tony causes trouble. He’d like that to go away. ISABELLA: I know it is hard to know what he would say if he were here. TONY: Well, that’s what he would say! He just wants his own way, and everyone else can do what he wants them to! CANTRICE: That’s not true! He works hard and needs to rest when he comes home. TONY: Yeah, like you don’t work hard at work and at home! (Shouting) This is stupid. Like anything is going to change around here! ISABELLA: You sound like you would like something to change, after all, Tony. This isn’t the easiest thing to do, so maybe you and Tawni could take some time to think about it before our next meeting. Will you do that? TAWNI: I could try. TONY (shrugs) Can I go now? ISABELLA: You and Tawni can go, and we’ll talk again at the next meeting. After Tawni and Tony leave, Isabella turns to Cantrice, who is crying. CANTRICE: I knew this wouldn’t work. You know, they say at church, the good Lord never gives anyone a burden they can’t handle. I wonder if they are right or not? I don’t think I can handle any more right now. Maybe I need to have a little less just to survive! I just don’t know why Tony can’t be more like Tawni. Can’t he see how much better it would be if he would be more cooperative? (Silence) You know, I guess school has been hard for him because he doesn’t read very well and he is in special classes for some subjects. ISABELLA: It sounds like school is much more of a challenge for Tony than Tawni. CANTRICE: You know, he doesn’t even talk to me anymore. He just lays around and watches television and doesn’t even want to talk to me. He definitely wants nothing to do with Charles. Cantrice and Isabella continued talking about her concerns for Tony. When Isabella mentioned she understood Tony had been violent toward Cantrice, Cantrice stated she had never really discussed it with Tony. She felt it was better to “start fresh and not bring up those bad memories from the past.” Isabella told Cantrice that she believed that they could work together and come up with some ideas to make things better for Tony and the whole family. They scheduled the next session for Tuesday evening. At that time Charles should be home. QUESTIONS 1. What did the practitioner do well in this session? 2. What, if any, mistakes did the practitioner make? 3. Identify the ways that the practitioner used skills to enhance understanding. 4. What are additional ways that the practitioner could have enhanced understanding? Give specific examples of what the practitioner could have said. 5. What two problems do you think the client is most concerned about? 6. Review what you learned in this module about assessing the client’s stage of change. What is this client’s stage of change? What information do you have to support your evaluation regarding the stage of change? What further exploration do you need to confirm that the client is in this stage of change? 7. Discuss the client’s level of motivation. What else would you want to explore to further determine level of motivation? 8. What strengths and resources did the practitioner identify in the client during the exchange? What might the practitioner have said to further highlight the client’s strengths? What questions should the practitioner ask to further explore strengths? 9. What else have you learned about level of stress and demands that might be impacting level of motivation? 10. What do you believe is the client’s level of hope? What information do you have to support that belief? 11. What did the practitioner say that might help the client believe that the practitioner could help him or her?
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Outline

Introduction

Body

Conclusion


Running head: INTAKE/ASSESSMENT NOTES

Intake/Assessment Notes
Name
Institution

INTAKE/ASSESSMENT NOTES

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Intake/Assessment Notes
Intake Notes

It is fundamental to prepare clear intake notes when working in the human services. This goes a long
way in assisting the human services professional to collect accurate data which will assist him/her to build a
better relationship with the client. These notes will focus on what is most important for the professional to
consider, document and pass along in each step of the human service process (Summers, 2016). For the
client case study presented, the following intake notes will apply:
Tell me about the individuals in your home,their age and your relationship with them.
The family consists of Cantrice Haywood (the mother, age 30), Anthony “Tony” Haywood (her son, age
12), Tawni Haywood (her daughter, age 9), and Terrence Clark (her son, age 3).
What is the ethnicity and current living neighborhood of the client?
This is an African American family. Currently the family lives in a townhouse apartment in a working class
neighborhood.
Tell me about your family background and your marital status.
Cantrice had been married ...


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