Counselor Responsibilities

MHANC CLP Community Residences

General

Refer to the Checklist of Routine Tasks and the Staff Task Calendar (both posted on the large
cork board) daily, every time you start your shift.

Every time you monitor any resident taking medications and you recognize that they are running
low (less than a one-week supply, assist them or monitor them in ordering a refill through their
pharmacy, right then at that moment (or immediately after Med Time). If there are no refills left,
have them call both their pharmacy and their prescriber. Their leaving a voicemail message is
fine.

Please have at least four goal sessions with each of your caseload residents per month, preferably
each week. Try to have at least one goal session for any of them per work shift. Only have one
type of goal session service type (DLS, MMT, HS, etc.) per month for each resident. Please write
the goal session’s progress note soon after having the session. Please use the standard format (the
opening and closing lines, review and assess progress, discuss and try to remedy
obstacles/limitation/problems, give suggestions, encourage/assist/monitor tasks to attain
objective, etc.). Write at least one collateral contact note for each case per month. Please print,
sign and file every note you write immediately.

Please make sure each resident in your caseload has a supply of all their medications at all times.
Assist/monitor them ordering refills from the pharmacy or prescriber as needed. Make sure the
ones who need Clozaril blood monitoring (TG, KR, TT, RZ, RL) get it done monthly. TT is not
approved to get it through Northwell Home Draw, but the others are. The Northwell Home Draw
requisition form is in the file drawer. They generally need a renewal every 6 months. This entails
getting a new blood work order from their prescriber, completing a requisition form, getting the
prescriber to sign the requisition form, submitting the form to Northwell Home Draw and
coordinating with the phlebotomist and your caseload residents to meet.

Please take the lead for each of your cases in all other matters as well, such as informing their
treatment team of any major changes or hospitalizations, helping them schedule appointments,
making and printing Provider Appointment forms (Foothold), and maintaining their charts (big
binders and medication binders).

Other documents you need to maintain, update, etc. include Med Delivery sheets, Goal Session
sheets (each row completed at each goal session), Face Sheets (Foothold and filed in Face
Sheet/first section), Consent Sheets (Foothold and filed in Residency Agreement section).

Other responsibilities include maintaining contact with their treatment teams, scheduling medical
appointments with them, and enforcing/encouraging compliance with orders from their medical
and health providers.
For all the Adult Day Health Care programs that our residents (RT, AW, JS, AZ) attend, the
nurses are more appropriate/prepared to contact about medical/medication/blood work topics
than are the primary workers/SWs.

There is a digital PDF copy of the Northwell Home Draw requisition form on the
MHACOMMON drive\CLP Forms\Cushman if hardcopies run out. There are digital copies there
of most forms we use.

Remember to call Mobile Crisis or 911 for a resident if necessary. Record the names of the
Mobile Crisis counselors and the name, badge number, ambulance company and ambulance
number of the 911 first responders.

If a resident is mildly or moderately agitated or requests psychiatric hospitalization but the

situation is not an emergency, before calling Mobile Crisis or 911 offer the resident a stay at
MHANC’s respite/hospital diversion house, Turquoise House (1-week stay maximum; requires
that the resident holds and self-administers his/her medications independently).

Goal Sessions & Their Notes

In goal sessions:

1. Ask if the resident remembers the objective.

2. Review the objective.
3. Review the previous goal session of the same service type.
4. Review any progress toward to objective (in parentheses at the end of goal session notes).
5. Assess any progress since the last session of the same service type.
6. Provide encouragement, validation, reinforcement, explanation, demonstration,
assistance, prompting, psychoeducation, insight, feedback, advice,
troubleshooting/problem-solving, coordination/logistics, etc.
7. Note the resident’s demeanor/attitude/state as well as responses to your questions,
suggestions, the discussion, etc. (for example: agreed, receptive, distracted, anxious,
combative, happy, sad, excited, tired, etc.).
8. Address and try to fix any obstacles/limitations/problems.
9. Help them make a plan, if necessary.
10. Review everything discussed in the present goal session.

When writing the goal session progress note:

1. Include as much as possible from the goal session (what’s listed above--did he/she
remember the objective, voice an opinion of the objective, was forthright/attentive about
progress toward the objective, responses/statements/expressions/questions, what you both
discussed, what he/she ignored or did not want to talk about, how you may have
redirected them/kept them on topic, etc.). Take notes during the session if you need to.

2. Use the standard format:

 a. First Sentence: Writer met with NAME to review and discuss his/her SERVICE
CODE objective of OBJECTIVE.
i. Example: “Writer met with Alex to review and discuss his CIR objective
of identifying five reasons why attending his day program is beneficial to
him.”
b. Last Two Sentence: To date, NAME [attained how much/what part of the
objective] (actual examples of what’s been attained, in parentheses). He/She has
[time left until end of service plan period] to [perform what portion is left of the
objective].
i. “He/she has ### days/weeks/months left to identify ### more.” Example:
“Within this service plan period, Alex has identified three reasons why
attending his day program is beneficial to him (he receives counseling, he
receives prescriptions and he enjoys seeing his friends there). He has one
month left to identify two more reasons.”
ii. If he/she attained the objective, make the last sentence: “He/she attained
this objective with ### days/weeks/months left to spare.”

3. Parentheses Usage
a. When writing goal session progress notes, remember to use parentheses to
indicate what progress that has been made near the beginning and the end of the
note.
b. Near the beginning, when you review progress already made, write something
like: “Writer assessed any progress made since his/her previous SERVICE CODE
session. In the previous session, he/she identified/implemented/etc. two PARTS
OF THE OBJECTIVE (drinking more water and walking one mile every week).”
c. Near the end, in the second to last sentence, write: “To date, NAME identified
three PARTS OF THE OBJECTIVE (drinking more water, walking one mile
every week and restricting caloric intake).”