# Case management: centre, documents, supervision, referral

Module 2 in one page. Counselling that is not documented, supervised, and connected to a referral network is a conversation, not a service.

## The four pillars

**1 · The counselling setting.** The room itself is an intervention: it says *you are safe here*.

- A peaceful, private, confidential room
- Comfortable seating at an angle, not across a desk
- Tissue, water, and a first-aid box
- Play and drawing materials for children
- A waiting space that protects privacy
- Barriers managed: noise, interruptions, smoke, alcohol
**2 · Documentation.** The individual file sits under a *code number, never a name*.

- Intake form
- Consent form (a Nepali template is in the CTEVT course pack)
- Session notes: presenting problem, interventions done, plan
- Assessment forms and checklists (Hopkins, PTSD)
- Case-update and progress reports
- Referral forms
- Supervision forms
- Client-satisfaction and termination forms
- The centre's register and daily record
Locked storage. Notes written the same day. Facts and observations, not judgments: write every note as if the client might one day read it, because they may.

**3 · Supervision.** Not inspection: protection, for the client and for you. Forms:

- Clinical supervision with a senior (case review, blind spots)
- Peer supervision (colleagues learning from each other)
- Your own supervision of CPSWs and trained teachers/health workers
- Bring your hardest case
- Bring your suicide-risk cases
- Bring the case you don't want to talk about: that one first
**4 · Linkage, coordination, referral.** Map your district before you need it. Know your contacts by name:

- **Psychiatrist and hospital**
- Senior counselor or psychologist
- Doctor
- Lawyer and human-rights organisations
- OCMC and safe houses
- VCT and drug counselors
- Physiotherapist
- Rehab centres and shelters
- Vocational training
- Schools and teachers
- Psychosocial-trained health post workers
- Child protection committees
- Clubs and mothers' groups
- *Traditional healers*: coordinate respectfully; they see your clients first
Referral is a skill: explain why, write the referral letter, take consent, give the client the information, follow up whether they arrived. **Refer up always for:**

- Psychosis
- High suicide risk
- Severe self-neglect
- Children in danger
- Anything beyond your training
**Composite scenario.** Priya, 24, first-episode psychosis, referred by a community health post. The health post worker noticed declining self-care and heard voices two weeks ago.

**Reasoning:** the referral is needed because psychosis is beyond the counselor's training scope and carries risk.

**The referral letter reads:** "Priya, 24, presents with two weeks of auditory hallucinations and declining self-care. Suspected first-episode psychosis. Urgent psychiatric assessment needed. Consent obtained from the client. Information given to the client about the referral."

**Outcome:** the psychiatrist confirmed the diagnosis and started antipsychotic medication; the counselor continued supportive sessions alongside the medical team.

Key points

1. Case management is the four pillars: assessment and plan, documentation, supervision, and linkage/referral.
2. Records are coded, secure and honest; undocumented counselling is a conversation, not a service.
3. Map your district's referral network before you need it: a named person and number at each service.
Learn more

Pick one, not all.

Free book[Where There Is No Psychiatrist: service organisation chapters](https://www.cambridge.org/core/books/where-there-is-no-psychiatrist/47578A845CAFC7E23A181749A4190B54): running a service with almost nothing.

Website[TPO Nepal: resources](https://www.tponepal.org): Nepali forms, manuals and training materials to model yours on.


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*Source: https://manoatlas.com/casemgmt · Licence: CC BY-NC-SA 4.0. Mano Atlas is an educational resource, not a diagnostic tool.*