Initial Intake Screening Script 2020

Circle of Care
Initial Intake/Screening Script
Can you tell me a little bit about what is going on for you and your family so I
can determine if our supports will be a good fit for you and your family?
(Begin to take notes here and fill in the areas that they talk about on
Welligent screening tool). You can also begin to collect information about
the death and make sure that they are appropriate for our services ie-Adult
Caregiver or Parent of children, Children who have experienced a death of a
significant person in their lives.
If you determine that services are initially appropriate let them know:
I will conduct a brief telephone intake to gather some general information
about your family, and the children who need support and a couple questions
to make sure that our services are an appropriate fit for peer support
groups. This phone/virtual intake will take approximately 10-20 minutes will
that work for you?
Usually at this point callers will want to know about the services
before they give you all their information so that they can think about if
peer support is what they are wanting. It also give the intake person a
chance to take the focus off of the potential participant and to build
relationship with the person you are talking to over the phone.
Our Services
Support groups – Groups are being held virtually on Thursday evening.

The purpose of our groups is so that the entire family can get support
together and be supported in community with other families coping with
similar losses. Adult groups have their own Zoom login as well as do Teens
12-18yrs, and their groups run from 6:30-8pm for our School Age 6-11yrs
group runs from 5:30-6:15 & Littles 4-6yrs from 5:30-6:15 (placement in
groups depends on where children are developmentally and determined by
further intake.
Each group is facilitated by our trained social work/MFT interns, community
volunteers and supervised by our Circle of Care staff. Adult group is
typically talk and processing, and children’s groups have grief related
activity and community building activities that help them develop peer
connections and opportunity for sharing, and talking about their feelings and
experiences.
It is important to know that peer support groups are not therapy or

counseling - yet they are very therapeutic for many families. Our
Facilitators hold space for the participants, but are not licensed individuals
and the support comes from being in a group of peers who can share their
stories, listen to each other, and relate to each other in their grief.
We don’t usually enroll families in groups until there has been at least 3
months since the loss since most families experience a period of shock and
hearing other people’s stories in a peer setting may not actually be helpful to
them. Participants need to have the capacity to be present and open to the
needs of the group and appreciate support of others who are grieving and
the stresses of parenting - and also be able to share their own experience,
reciprocate support with non judgment
It would be great to know if you have had any experience before in a support
group or group processing setting before. For example, on a work team,
community group, family groups or classes. How did it go?
At this point, are you interested in moving along in the intake process?
I need to start by gathering some contact from you.
What is your full Name?

Relationship to children? (if different than mother of father)
And your Date of Birth?
Your home address where we can mail you information?
And your home phone number?
Is it ok to leave messages there?
Is it ok to leave messages there?
Do you have a cell number?
Do you have an email address?
What is your youngest child’s name?
How old is he/she?
What is his/her date of birth?
What school does _____attend?
Next child’s name, DOB, School Attends etc
What is your family’s ethnicity? (Some people ask why – You can tell them
we try gather as much information as we can so that we can serve your
family better. They have the option of opting out of answering that question
if they don’t want to and you can reassure that that is not a problem)
What language do you speak at home?
When was ____diagnosis made? the date of diagnosis?

When did he/she die?
How did ____ die?
What type of cancer did they have?
Can you tell me a little bit about what is going on for the children? or
anything you would like to add about how the children are coping?
What does your support system look like currently?
What was the most challenging part of your life before the death?
What has been the hardest since the death?
In our experience families who are potentially coping with other challenges
in addition to grief, like drug addiction or alcoholism, abuse, severe
depression, or thoughts of self harm or harm to others may not be a good fit
for our services. Can you tell me a little about your experience with any of
these types of situations/challenges?
If needed, we have the ability to make referrals for individual
counseling to help you support around these challenges as they are typically
more pressing to address before grief.
If you are able to determine right away that services are not
appropriate:
Offer them some referrals. If you don’t can’t think of any referrals at the
time they are on the phone with you, ask them if you can take down some of
their contact info so that you can look up some resources for them and call
them back and or email them
If you at all feel like they ask you a question that you don’t know the answer
to, tell them that you will consult your supervisor and get back to them.
Intakes will vary in length, and the amount of information that you are able
to gather from the client. If they do not want to answer a question, or it is
difficult for them assure them that we can create some space and time to
connect in again when they are able to talk.
Close of Intake Screening:

Thank you for sharing with me your families experience and for trusting me
with your story. We hope that we will be able to provide some supports for
you and your family during this difficult time and the next step is that I will
consult with my supervisor to asses if groups are going to be a good fit for
you, and I will be contacting you back about our next steps. I also can send
you some helpful information in email around talking to children about death,
grief and other tools that might help support you until we talk again.
Follow UP:
Screener will bring the intake back to our staff meeting, or Director office
hours if they need to consult on appropriateness. If appropriate they will be
slotted into groups and given welcome email and links to the group.
Helpful Guidelines for Appropriate referral:
● Must be out of shock phase of grief and ready to process feelings in a

groups setting. This is usually about six to eight weeks after a loss,
but can be within weeks of a diagnosis or loss, depending on the
circumstance. The reason for this time period is so that participants
have the capacity to be present to for the stories and experiences of
fellow participants in addition to sharing their own experience.
● Good to fair communication skills.
● Ability to learn to listen to & share time fairly with other group
members.
● Needs and appreciates support of others who are grieving and/or

living with illness in their family and the stresses of parenting, and can
also reciprocate support.
● Was functioning adaptively in life prior to the recent death of a loved

one
● Have ability to listen to or being able to support others in the group
● If problems with drugs or alcohol are identified, further exploration

is necessary before determining participation eligibility. May not use
any drugs or alcohol before or during group sessions.
● For Inperson groups:Ability to have regular access to transportation

and commit to regular attendance in a group. (understanding
transportation issues related to ongoing illness.)
● Not actively suicidal, no recent history of psychiatric hospitalizations
● No major mental illness (personality disorders, severe depression,

suicide attempts, psychotic disorders)
● If primary losses that are non-human or not illness/death related (e.g.
pet loss, divorce, loss of job etc.) they are not appropriate for our
groups.

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Circle of Care

Initial Intake/Screening Script

Support groups – Groups are being held virtually on Thursday evening.

It is important to know that peer support groups are not therapy or

What is your full Name?

Next child’s name, DOB, School Attends etc

What language do you speak at home?

When was ____diagnosis made? the date of diagnosis?

What does your support system look like currently?

What has been the hardest since the death?

Close of Intake Screening:

Helpful Guidelines for Appropriate referral:

● Must be out of shock phase of grief and ready to process feelings in a

● Good to fair communication skills.

● Needs and appreciates support of others who are grieving and/or

● Was functioning adaptively in life prior to the recent death of a loved

● Have ability to listen to or being able to support others in the group

● If problems with drugs or alcohol are identified, further exploration

● For Inperson groups:Ability to have regular access to transportation

● Not actively suicidal, no recent history of psychiatric hospitalizations

● No major mental illness (personality disorders, severe depression,

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