Initial Assessment

1. Initial assessments are scheduled for 50-minute blocks of time. The administrative staff schedule the initial assessment appointments for each clinician. 2. Clients are asked to arrive at the office 15 minutes prior to their appointment to complete forms, or to complete most of them in advance using the link they receive in their email reminder. Once the client has completed all paperwork at the kiosk, it is available for view by the clinician in Titanium, and is quickly reviewed before meeting with the student. 3. If the client is late for their appointment, and the trainee is unable to perform a complete assessment, the trainee may consult with their supervisor or an available staff member to determine whether the client needs to be seen that day by a drop in clinician for a more thorough assessment, e.g., if the client appears seriously depressed or unstable. 4. The trainee will normally pick up the case for which they have done the initial assessment. If, upon meeting the client, there is uncertainty about the appropriateness of the assignment, the trainee will tell the client that they will consult with a supervisor and contact the student as soon as possible, but within 24 hours, regarding disposition. If a decision cannot be made by the senior staff person being consulted, the Deputy Director and/or Director of Training should be consulted. 5. If, after a case has been assigned, new concerns about the client’s disposition arise for the initial assessment clinician, they should be discussed with the supervisor and/or Deputy Director or Director of Training. This consultation should take place as quickly as possible after the concerns arise. Many students whose care does not fall within our mission should be referred to clinics or private practitioners off-campus. Supervisors will assist their supervisees with making referrals until they are more knowledgeable about treatment providers. The following is a list of factors trainees may refer to when considering disposition:

  • Stability status (degree to which student is stable enough to be referred)
  • Political/Personal (the student was personally referred to us by someone in the VPUL division or in another campus department, and the referring party wants the student to be closely monitored by a clinician at CAPS)
  • Financial (the student does not have the financial ability or insurance coverage necessary for obtaining therapy off-campus)
  • No Appropriate Referral (we are unable to find an outside treatment provider that would meet the client’s needs due to specialized clinical or multicultural factors)
  • Transportation (student does not have the resources necessary to reach providers)
  • Refusal (student is unwilling or not ready to accept a referral)

6. If a trainee knows in advance that they will be unavoidably absent because of illness etc.and therefore will not be able to conduct the initial assessment, that person should notify the front desk staff as early in the day as possible. The client will be asked to come in to drop in hours for an assessment and/or rescheduled in the next available IA slot.

Initial Assessment Documentation

It is important to fully document drop in and initial assessment evaluations as soon as possible so that all the information is available to the rest of the staff. Drop in contacts should be documented the same day and the initial assessment evaluations within 24 hours.

If a trainee begins initial assessment paperwork and is not able to complete it that day, it may be completed the following day. Clinical judgment should be exercised when making decisions about how quickly the initial assessment needs to be finished. For example, a high-risk case needs to be documented immediately, (i.e. same day) whereas a referral out has a lower priority, (i.e. next day).

Any hardcopy paperwork (Permission to Video/Record Session, any consent forms) should be placed face-down in scan box in the mailroom.

All notes must be signed in Titanium by the trainee and forwarded to their supervisor for review.

Supervisory Review

Once the initial assessment is fully documented, the supervisor reviews it and, after all revisions are completed, signs it.

Follow Up

Each clinician is responsible for following up and closing each case that they refer out at any point in treatment.

Training Guidelines for Preparing Trainees to Conduct Initial Assessment Appointments

Step 1: Trainees attend initial assessment training during orientation. During this seminar or immediately thereafter, trainees will view the sample initial assessment video that is assigned by their supervisor. This video can be located in the G drive.

Step 2: Trainees write a full intake report, using the template in Titanium, of the video they viewed. This report is reviewed by the primary supervisor(s). Depending upon the feedback given to the trainee, a supervisor may request a rewrite of the report.

Step 3: Trainees watch additional intake videos, which can be found in the G Drive. They discuss the interviews in supervision where any questions are answered. Supervisors may require a trainee to write a report for each or any of the videos viewed.

Step 4: When the primary supervisor(s) determine that the trainee is ready, the trainee performs the initial assessment while being videotaped. This is scheduled during an hour when the supervisor or appointed senior staff member is free so that if the client refuses videotaping, the staff member may conduct the intake, or alternately, if the client agrees, the trainee may conduct the intake while the supervisor observes. This process is repeated until the trainee’s supervisor(s) determine readiness for Step 5.

Step 5: The trainee performs the initial assessment alone. When the supervisor believes the trainee is ready, she/he moves on to Step 6.

Step 6. For psychology externs and social work interns:

The trainee schedules initial assessments at a rate determined in consultation with the supervisor(s) until the caseload is full. Determination of when a trainee’s caseload is full is made in consultation with individual supervisors. After that, the trainee schedules initial assessment slots at a rate that is determined again in consultation with the supervisor(s) or in the case of postdoctoral fellows and psychology interns.

For psychology interns:

The intern schedules two intakes every week.

For postdoctoral fellows in psychology:

The postdoc schedules three intakes per week.

Link to main CAPS website

Training Program