SOCIAL WORK CASE NOTE

Client: [Name]
Date of birth or ID: [Identifier]
Date and time: [Date, start and end time]
Social worker: [Name, credentials]
Program: [Hospital unit, community agency, school, or other program]

CONTACT DETAILS
Contact type: [Home visit, office, phone, video, bedside, or community]
People present: [Client and others, with their role or relationship]
Consent: [Consent to share information, with whom, and any limits]
Purpose: [Why the contact happened, linked to the client's goals or case plan]

OBSERVATIONS
Client presentation: [Appearance, mood, behavior, and engagement, as observed]
Environment: [Home or setting conditions, safety, basic needs, accessibility]
Client's report: [Needs, changes, and priorities, in the client's words on key points]

INTERVENTIONS
Resource linkage: [Referrals made, applications started, programs contacted]
Advocacy: [Contacts made on the client's behalf, and the outcome]
Counseling and support: [Supportive counseling, problem-solving, education]
Care coordination: [Team members and services coordinated]

CLIENT RESPONSE
Response: [How the client responded, what they agreed to, and any concerns or disagreement]

COLLATERAL CONTACTS
Collateral: [Person or role, agency, method, what was shared or learned, consent on file]

SAFETY CONCERNS
Risk screen: [Self-harm, harm to others, abuse, neglect, exploitation, or none identified]
Actions taken: [Safety planning, reports made as the law requires, supervisor consulted]

TASKS AND NEXT STEPS
Task 1: [What, who is responsible, due date]
Task 2: [What, who is responsible, due date]
Task 3: [What, who is responsible, due date]
Next contact: [Date, type, and purpose]

Signed: [Social worker name, credentials, date and time]