At this point, I realized that I needed to engage with her. Her reaction to my presence at the beginning interrupted my idea of a positive engagement. I quickly started to focus on her baby and used the baby as a piece to engage with her. I made comments like, “Congratulations on your baby, she is precious”. Then I asked her simple questions like, “Have you picked out a name yet?” After my redirection to the baby, the client was able to warm up a little to me and engaged in the conversation about her baby. I realized that with many clients, you have to allow them to lead the interview instead of you trying to impose your questions directly to get the answers you need to write the note.
During the engagement process, I was able to have a get a lot of the questions of the psychosocial assessment answered without the client realizing it was for an assessment. Because we were talking about her baby, I was able to get answers on who the father is and if he is going to be involved in the care of the baby. I was also able to get answers on whether she was ready to take the baby home and what her support system looked like. Because we were still focusing on the baby to engage, it made it easy for the client to talk to me. The next step was another difficult moment in the