Neftaly Therapeutic Psychosocial Support Programme

Client Management File

This structure is suitable for:

✅ Department of Social Development (DSD)
✅ Social Workers & Psychosocial Counsellors
✅ Trauma & Mental Health Programmes
✅ GBV & Vulnerable Group Support
✅ Case Management & Monitoring
✅ POPIA Compliance Audits

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NEFTALY THERAPEUTIC PSYCHOSOCIAL SUPPORT PROGRAMME

CLIENT MANAGEMENT FILE

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SECTION 1: CLIENT FILE COVER PAGE

Client Information

Field	Details
Client File Number
Date Opened
Programme Site
Practitioner Name
Case Manager
Referral Source
Client Name & Surname
ID / Passport Number
Date of Birth
Gender
Contact Number
Residential Address
Emergency Contact
Relationship
Contact Number

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SECTION 2: INFORMED CONSENT FORM

Client Consent Declaration

I, ________________________, voluntarily agree to participate in the Neftaly Therapeutic Psychosocial Support Programme.

I understand:

• Services are confidential.
• Information will be protected under POPIA.
• Participation is voluntary.
• I may withdraw at any time.

Client Signature: __________________

Practitioner Signature: _____________

Date: _____________________________

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SECTION 3: CLIENT INTAKE ASSESSMENT

Background Information

Item	Details
Marital Status
Employment Status
Education Level
Household Composition
Income Source
Disability Status

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Presenting Problems

☐ Trauma
☐ Depression
☐ Anxiety
☐ GBV
☐ Substance Abuse
☐ Family Conflict
☐ Grief & Loss
☐ Behavioural Challenges
☐ Other: ___________

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Risk Assessment

Risk Area	Low	Medium	High
Suicide Risk	☐	☐	☐
Abuse/Violence	☐	☐	☐
Neglect	☐	☐	☐
Mental Health Crisis	☐	☐	☐

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SECTION 4: PSYCHOSOCIAL ASSESSMENT REPORT

• Emotional Functioning
• Social Relationships
• Family Environment
• Behavioural Observations
• Coping Mechanisms
• Support Systems

Practitioner Notes:

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SECTION 5: INDIVIDUAL SUPPORT PLAN (ISP)

Identified Need	Intervention	Responsible Person	Timeline	Expected Outcome

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SECTION 6: COUNSELLING SESSION NOTES

Session No	Date	Type of Session	Key Issues Discussed	Intervention Used	Progress

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SECTION 7: GROUP THERAPY PARTICIPATION

Date	Group Name	Topic	Facilitator	Client Participation

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SECTION 8: HOME VISIT REPORT

Date	Address Visited	Purpose	Observations	Action Required

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SECTION 9: REFERRAL FORM

Referral Date	Organisation	Service Required	Reason	Outcome

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SECTION 10: PROGRESS REVIEW

Review Date	Progress Achieved	Challenges	Adjustments Made	Practitioner

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SECTION 11: INCIDENT REPORT

Date	Incident Description	Action Taken	Reported To

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SECTION 12: CLIENT ATTENDANCE RECORD

Date	Service Type	Practitioner	Signature

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SECTION 13: EXIT / CASE CLOSURE REPORT

Reason for Closure

☐ Goals Achieved
☐ Referral Completed
☐ Client Withdrawn
☐ Relocation
☐ Non-attendance
☐ Other ___________

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Outcome Summary

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Final Recommendation

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Practitioner Signature: __________________

Supervisor Signature: __________________

Closure Date: ___________________________

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SECTION 14: CONFIDENTIALITY & POPIA COMPLIANCE

All information contained in this file is confidential and protected under:

• Protection of Personal Information Act (POPIA)
• Social Service Ethical Standards
• Mental Health Confidentiality Principles

Authorized Personnel Only.

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✅ Recommended Physical File Divider Structure

Client File
│
├── Cover Page
├── Consent Forms
├── Intake Assessment
├── Psychosocial Assessment
├── Support Plan
├── Session Notes
├── Home Visits
├── Referrals
├── Progress Reviews
├── Attendance
└── Closure Report

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