Social Service Interview Questions Step 1 of 5 20% Date of Interview MM slash DD slash YYYY Agency Questions:Name of Agency Address Street Address Address Line 2 City ZIP / Postal Code Contact Person First Last PhoneTime of OpeningPick a Time6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pmTime of ClosingPick a Time12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pmWhat social services do you offer? (select all that apply)Child Care and Parenting After-school Program Camp or Summer Program Car Seats Safety Checks Child Care Developmental Screening or Assessment Parenting Skills Classes Parenting Support Program Youth Mentoring Dental, Vision, and Hearing Dental Care Eye Care Glasses and Contacts Hearing Aids Hearing Test Education Adult Basic Education Art Classes and Cultural Activities College Readiness Program Continuing Education CPR and First-Aid Training Early Learning Program High School Equivalency Classes and Testing Preschool School Search Assistance Tutoring Employment Career Counseling Job Search Assistance Job Training and Readiness Volunteer Opportunities Youth Employment Program Exercise and Recreation Group Fitness Classes Gym or Workout Facility Personal Training Recreation or Community Center Sports Clubs and Recreational Activities Swim Classes Weight Loss Program or Support Group Yoga of Pilates Classes Family Planning and Pregnancy Abortion Counseling and Services Adoption Coordination and Services Birth Center Services Breastfeeding Support Child Birth Classes New Parents Assistance Reproductive and Sexual Health Care Financial Stability Disability Application Assistance Emergency-only Financial Assistance Child Care Financial Assistance Health Insurance Application Assistance Identity Document Application Assistance Medical Expense Assistance Other Financial Assistance Personal Finance Education Public Benefits Application Assistance Rent and Mortgage Payment Assistance Social Security Application Assistance Student Loan and Scholarship Application Assistance Tax Filing Assistance Temporary Cash Assistance for Families Unemployment Benefits Application Assistance Utility Payment Assistance Veterans Benefits Application Assistance Food and Nutrition Baby Formula and Baby Food Community Gardening Cooking and Healthy Eating Classes Food Pantry Food Services Coordination Fresh Fruits and Vegetables Groceries Group Meals Meal Delivery Nutrition Counseling SNAP Registration Assistance Soup Kitchen or Free Meals WIC Registration Assistance Second Choice Third Choice Free and Low-Cost Goods Cleaning Supplies Clothing and Shoes Diapers Home Goods Other Free or Low-Cost Goods School Supplies Toiletries and Personal Hygiene Products Winter Clothing and Coats Health Care Assisted Living Facility Case Management and Social Workers Chronic Disease prevention Program Chronic Disease Self-Management Program Complementary and Alternative Medicine Dialysis Emergency Room Health Care Services Coordination Health Education Classes Health Screening HIV Care Hospice and Palliative Care In-Home Nursing Care In-Home Personal Care Nursing Home Other Specialty Healthcare Physical Rehabilitation Therapy Primary Care Transitional Health Care Urgent Health Care Vaccines Health Care Supplies Assistive Devices and Technologies Blood Pressure Monitors Blood Sugar Management Supplies Breast Pumps Masks and Other personal Protective Equipment Medical Supplies Counties and Tribal Communities in Northern Arizona: (check all that apply) Apache County Coconino County Havasupai Tribe Hopi Tribe Kaibab Band of Paiute Indians Mohave County Navajo County Navajo Nation San Carlos Apache Tribe White Mountain Apache Tribe Yavapai-Apache Nation If applicable, please upload a copy of your intake form.Intake Assessment FileMax. file size: 80 MB.If you do not have an intake form to upload, please fill out your client questions below. What intake questions are clients asked? (check all that apply) Date of Birth Sex Gender Preferred Pronouns Referral Source Access of Previous Services What caused the patient to seek services? Proof of residency Income Bracket Docementation of citizenship Current risk factors Who lives in the client's household Is the client at risk of losing housing Basic needs assessment Social determinants of health Highest level of education Employment Status Military Status Disability Status History of abuse of trauma Client's cultural background Preferred language Past or present medical problems Current medications Any recent inpatient hospitalizations What substances client utilizes or depends upon Other If Other Client Based QuestionsOutreach Efforts: (check all that apply) Advertisements Community Events Email Flyers Phone Calls Presentations Social Media Word of Mouth Referrals Who refers your clients? Family Friends Social Worker School Doctor Other Explain Other Referral Type Target PopulationsPopulation Young Children (0-5) Children (5-12) Young Adults (12-18) Adults (18-55) Elders (55+) Families Socioeconomic Status Income below 100% FPL Income between 100 - 150% FPL Income between 150 - 200% FPL Income above 200% FPL Domographics Black or African American Native American Hispanic Asian White Native Hawaiian or Pacific Islander Other Other Fees-create option to upload fee assistance documentation No Yes If yes, select all that apply Sliding Scale Insurance Accepted Fee Assistance Available If yes, please upload document(s)Max. file size: 80 MB.Client CareIs one-on-one case management an option for families?Please Select Yes/NoYesNoLength of Case Management? Weeks Months Years Indefintely N/A Other If Other How often does the case manager meet with the client(s)? Weekly Bi-Weekly Monthly Bi-Monthly N/A Other: If Other How do case managers get in contact with the clients(s)? Email Phone Text Virtual (IE: Zoom) In Person School N/A Other: If Other How is termination of services determined? When max time with client has been reached. When case manager determines goals have been met. When presenting problems have been resolved. N/A Other: If Other: After termination occurs, is there follow-up?Please select an optionYesNoPlease explain your follow-up procedures One-on-One Case Management ImplementationWhat case management strategies do you use with your participants? Assessing needs through an interview Assessing needs through an intake form Assessing strengths through an interview Assessing strengths through an intake form Refer to outside services Refer to internal services Monitor access of services Side by side participation in accessing services Provide trainings or coaching (ex. Class on parenting skills) Modeling skills (ex. How to search for a job online) Strength-based questioning Relationship-building 1:1 Relationship-building with small group of participants Relationship-building activities (ex. community events) Goal setting with the participant Coaching (ex. Support thinking through how to complete a resume) Provide incentives for completing programs or goals Other: Is the intake form referred to throughout the treatment process?Please select an optionYesNoAre children involved in the case management process?Please select an optionYes (please specify)NoIf Yes Δ
