Social Worker-TR

JOB SUMMARY

Social Workers establish and maintain a therapeutic relationship with individuals and their families by effectively utilize therapeutic relationships with appropriate treatment/services, that their legal and human rights are protected, and that services and resources are used effectively and consistently utilizing professional social work skills. They may review the individual's psychiatric, medical, and other case records and discuss issues with families and other members of the treatment team.

Complete admission screening; conduct psychosocial assessments; make treatment recommendations; participate in treatment planning; provide social casework services; provide individual, group, and family therapy; assess availability of services; serve as consumer advocates; develop and implement discharge plans; and coordinate services with community providers. Stay OnTrack, a step-down, peer lead, continuing care model that bridges the gap between OnTrack NY discharge and readiness for outpatient services.

This trauma-informed, client-centered program will offer flexible, lower-intensity support tailored to individual needs, helping participants maintain progress and prepare for long‑term recovery. Participants of Stay OnTrack will receive Clinical Support:
Psychiatric assessments, medication management, and care coordination;
Counseling & Case Management;
Peer Support; and Wellness & Psychoeducation:
Coaching on coping skills, self‑management, and social integration.

• Interviews individual after a thorough review of the record to construct the psychosocial assessment.
• Obtains psychosocial history by interviewing the individual, the family, significant others, and former service providers to formulate clinical recommendations for therapeutic interventions.
• Assess individuals' treatment needs.
• Prioritizes the individual’s treatment needs; assesses impact of treatment on the individual and the family; assesses ability of significant others to assist in the treatment planning process; and involves the individual and significant others in a comprehensive treatment plan; and in some settings determines which individuals are appropriate for other levels of care.
• Participates in the development of a written comprehensive individualized treatment plan that is based on the assessment of the individuals clinical needs; determines need for services and ensures that referrals for ancillary, support and consultative services are noted and made; reviews and updates individual treatment plan according to all applicable guidelines and in response to clinical change; and ensures that arrangements are made and documented for continuation of care well in advance of individuals planned departure.
• Provides individual therapy to enhance social, emotional, and behavioral functioning.
• Advises the individual and family about the nature of the illness, needed and available services and how to access them.
• May identify, coordinate, and plan for the individual's financial needs.
• May identify and provide intervention to individuals in crisis in a range of settings; or provide consultation to others to enable them to appropriately intervene.
• Assesses the individual's readiness for discharge; identify needed resources; works with consumers/patients, families identify needed resources; works with consumers/patients, families, and providers to link him/her with appropriate resources; may conduct follow‑up visits.
• Prepares required progress notes, treatment team recommendations, written and verbal reports, discharge plans, and other documents within required time frames.
• As an integral member of the treatment team, ensures that all relevant clinicians are kept informed of the individual's clinical needs, family social adjustment, services needed and their availability through clear documentation of the record.
• Conducts group life skills training, treatment, or group counseling sessions.
  • Prepares an outline of objectives and conducts sessions according to the treatment program schedule.
  • Meets with assigned group according to treatment schedule.
  • Conducts specialized groups to meet the needs of target populations:
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