Field Agency: ________________________________________________
Field Instructor: ______________________________________________
IDENTIFYING INFORMATION: Identifying pertinent information (remember: always disguise client’s name to protect confidentiality)
PURPOSE OF THE SESSION: Briefly state whether there are any specific goals to be achieved, the nature of the referral, nature of the initial or presenting issues, the student’s plans, and the client’s agenda.
OBJECTIVES FOR THE INTERVIEW. Briefly state whether there are any specific goals to be achieved, the nature of the referral, nature of the initial or presenting issues
PROCESS RECORD: A word-for-word description of what happened as well as the student can recall. A description of any action or nonverbal activity that occurred.
|Non-verbal behavior of the client||Process
(Gut Level Feelings)
of Social Work
Theories and Skills
|Field Instructor’s Comments|
ASSESSMENT OF THE CLIENT/ASSESSMENT OF YOUR OWN WORK A summary of the student’s impressions of the client. This is a summary of the student’s analytical thinking about the entire interview, including their role.
NEXT STEPS THAT YOU PLAN TO DO/QUESTIONS Future plans. Identification of unfinished business, identification of short and longer-term goals.
IDENTIFICATION OF QUESTIONS FOR FIELD INSTRUCTION. This provides the student with the opportunity to build upon their ability to become autonomous workers.
FIELD INSTRUCTOR’S SIGNATURE: _________________________________________________
Field Instructor’s input and signature required for maximum 5 points.