Youth Worker Template

Youth Worker Documentation Notes

A professional Youth Worker template for healthcare professionals.

About this template

Boost your youth support services with our comprehensive 'Youth Worker Documentation Notes' template. Perfect for youth workers, social workers, and community support professionals, this template streamlines your client record-keeping. Easily document critical information such as the context of engagement, presenting concerns, and the impact on a young person's life. Accurately capture observations, referrals made, and detailed follow-up plans, ensuring continuity of care and effective intervention. Heidi, our AI medical scribe, intelligently fills these sections directly from your session transcriptions, saving you valuable time and ensuring no vital detail is missed in your youth worker progress notes.

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**Context of engagement** Client was referred by their school counsellor, Mrs. Green, due to increasing truancy and reported withdrawal from social activities. The purpose of this initial engagement session was to establish rapport and understand the underlying reasons for their recent behavioural changes. The session took place at the youth centre, providing a neutral and confidential environment. **Description of concern** The client, [Sarah J.], a 15-year-old female, expressed feelings of sadness, isolation, and anxiety regarding returning to school. She reported difficulty sleeping, a loss of interest in hobbies she previously enjoyed, such as playing netball, and frequent headaches. She also mentioned occasional panic attacks when contemplating social interactions. **Timing, cycle and pattern** The presenting concerns began approximately three months ago following a change in her friendship group at school. Her truancy started around six weeks ago, occurring primarily on Mondays and Fridays. The feelings of sadness and anxiety are more pronounced in the evenings and before school, often triggered by social media interactions or thoughts of school. The headaches are intermittent but have increased in frequency over the past month. **Impact on functioning and relationships** [Sarah J.] has significantly reduced her attendance at school, impacting her academic performance. Her relationship with her parents has become strained due to arguments about school attendance and her withdrawn behaviour. She has isolated herself from her usual friend group and spends most of her free time alone in her room. Daily activities like eating regular meals and maintaining personal hygiene have also been affected. **Observations** During the session, [Sarah J.] presented with a dishevelled appearance, wearing oversized, dark clothing. Her affect was flat, and her mood appeared subdued. She made minimal eye contact initially but gradually became more engaged as the session progressed, particularly when discussing her hobbies. She spoke softly and her posture was slouched. **Referrals** [Sarah J.] was provided with information regarding local mental health services, specifically a youth counselling service specialising in adolescent depression and anxiety. A referral to the school's educational psychologist was also discussed, with parental consent to be obtained. Resources on managing anxiety and sleep hygiene were provided. **Follow up plan** A follow-up session has been scheduled for 1 November 2024, at 14:00 at the youth centre, to further explore coping mechanisms and potential avenues for re-engagement with school and social activities. Goals for ongoing support include improving school attendance, re-establishing positive social connections, and developing healthy coping strategies for anxiety. [Sarah J.] agreed to consider contacting the mental health service and discuss the educational psychologist referral with her parents.

**Context of engagement** [Describe the referral source, reason for engagement, and context of the session.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs of full sentences.) **Description of concern** [Describe the presenting concerns, including emotional, behavioural, and physical symptoms reported by the client.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs of full sentences.) **Timing, cycle and pattern** [Document the timing, frequency, and any cyclical or recurring patterns of the concerns. Include onset, duration, and triggers.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs of full sentences.) **Impact on functioning and relationships** [Outline the impact of the concerns on various life domains, such as school/work, family relationships, social life, and daily activities.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs of full sentences.) **Observations** [Note objective observations made during the session, including the client's appearance, affect, mood, and engagement.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs of full sentences.) **Referrals** [List any referrals made or recommended, including medical, psychological, or other specialist services. Note any resources provided.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs of full sentences.) **Follow up plan** [Detail the plan for future sessions, including specific actions to be taken, scheduled appointments, and goals for ongoing support.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs of full sentences.) (Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank)

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