How do you write a intake interview for vocational rehabilitation?

Initial Interview Narrative should include:

Reason for referral

Medical Problems and Cause

Limitations imposed by the disability/disabilities

Personal/Social/Family and Living Situation

Work History

Education and Training

Financial

Legal Concerns

Transportation

Observations of needs and/or Interests

State that explanations were given of rights, responsibilities, and confidentiality

Next Steps

REFERRAL/PRESENTING INFORMATION:

1. The applicant was referred by his doctor's office.

2. The interview took place at the VR program. Present during interview were VRC AB and the applicant.

3. Why was the applicant referred? The applicant is seeking assistance

with short-term vocational training, job development and placement

services. He expressed interest in seeking employment in a sedentary

setting. Vocational interest - Computerized Accounting. Full-time

employment is preferred.

4. Was the applicant a prior consumer of the Department of

Rehabilitation? No.

5. The applicant is involved with the following agencies? None at this

time.

MEDICAL/PSYCHOLOGICAL (Information per disability)

1. Presenting disabilities at intake are:

Primary Disability - Mental impairment (PTSD, Depression, Anxiety

Disorder).

Secondary Disability - Lower Back pain, degenerative disc disease.

Other medical issues/conditions reported - Visual impairment (left eye

25/30 vision). There is an appointment pending for an eye exam and

glasses.

2. Onset of disability: Per the applicant's comments, he experienced a

serious injury - was attacked and beaten with a bat by two men April 6,

2010. Was hospitalized for five days. The applicant had reconstructive

surgery of the face August 2010 and of the left eye April 2011. He has

been participating in group therapy for the past 2 1/2 months. Also meets

with Dr. Baca, Ph.D. once a month.

3. Medications: The applicant indicated he was prescribed medication

(Prozac - 20 mg) and has been on taking it for the past two months.

SIGNIFICANCE OF DISABILITY/FUNCTIONAL CAPACITIES IMPACTED: The applicant's disability appears to significantly affect the following

functional areas: Communication; Work Skills; and, Work Tolerance.

VOCATIONAL IMPLICATIONS: We discussed the applicant's disability and

vocational impediment connection. Based on information provided by the

applicant, the disability presents a significant impediment to employment

due to difficulties with anxiety, self-doubt, concentrating on work

activities and staying focused on task. Has significant problems with

crowds. Stimuli that trigger physiological or psychological reactivity in

the applicant will be an impediment in the work environment. Basic work

procedures and following instructions could diminish the applicant's

effectiveness in the workplace and his ability to carry out work-related

simple questions, to request assistance, and to respond appropriately to

criticism from supervisors.

SOCIAL, CULTURAL and ENVIRONMENTAL: The applicant is a single male (never married) with one daughter. Daughter lives with her mother. The applicant was born in City and raised in City (moved to City at age 6).

Moved to City in 2000 and returned to City 2005. The applicant has

two older siblings. The applicant's mother lives in City; father is

deceased. The applicant states he has a good rapport with family members. Housing situation - the applicant resides in a home with a friend. No one else in the home. Mode of transportation - the applicant currently relies on the public transit system for transportation.

LEGAL ISSUES: The applicant stated he has a suspended driver's license

due to a DUI. He is required to pay a reissue fee to the DMV and also pay

fines to the court so that he can get his license reinstated. Plans on

taking care of this matter this week. Also owes about $3,000.00 in child

support back pay.

VOCATIONAL INFORMATION: The applicant's work history consist of

employment as a Security Dispatcher/Security Officer, Office Clerk,

Bookkeeper (see Employment Record in case file). He last worked in 2008.

The applicant does not have a resume and will have difficulties

explaining breaks in work history during an interview. He will require

assistance with pre-employment preparation, resume letter preparation,

preparation with job interviews, and assistance with seeking and gaining

employment.

EMPLOYMENT FACTORS: Strengths - the applicant's work history demonstrates strong transferrable skills working with computers. Resources - the applicant is active in therapeutic activities. Priorities - obtaining

short-term training and employment is a significant priority for this

individual. Concerns - may need to check for use of chemical substances,

which the applicant may be using to help mask the pain of intrusive

memories, flashbacks, or anxiety connected to the trauma (the applicant

stated he drank about two weeks ago).

ECONOMICS: Current income emanates from Unemployment Benefits ($227.00 weekly less 25 percent for child support payments). No other income reported. The applicant has medical coverage via the County of City - Medically Indigent Services Program (MSP).

EDUCATIONAL/TRAINING: The applicant completed high school and some formal post-secondary education (has about 41 units). Last attended college in 1996.