7.1 Phase 1: Referral Process

The first phase of case management is the initial referral process.

Referrals are made by non-governmental agencies, community based organizations and individuals, and/or UN agencies. All documentation and referral forms are completed accordingly. Case Managers respond and acknowledge receipt of a referral within three working days. A first meeting with the client should be scheduled within seven to 14 days of the referral.

A suggested referral process is listed below:

  1. Referrals may be made by non-governmental organizations, the UNHCR, community based organizations or individuals.

  2. When a case is referred for case management, ensure the referral agency accurately fills in the referral forms in Annex 8a or Annex 8b with relevant documentation. The completed forms may be emailed to the relevant persons listed on the form (at the top section).

  3. The Case Supervisor must respond and acknowledge receipt of the referral within three working days.

  4. If a child self-refers, ensure collection of the following information:

  5. Name

  6. Age or date of birth

  7. Country of origin

  8. Whether unaccompanied or separated

  9. Telephone number

  10. Languages spoken

  11. Exact location or where they are staying

  12. With whom are they staying (family, single men, employer)

  13. Copies of relevant identity and medical documents

  14. The Case Supervisor will screen and make a preliminary assessment as to whether the case falls within the scope of the case management process based on the information in the form.

  15. However, if upon referral the child is deemed to be in immediate danger, the Case Supervisor must contact relevant agencies or organizations for the child to be placed in a temporary shelter, while waiting for full screening or an intake interview to be conducted.

7.2 Phase 2: Screening Process

Following a referral, a screening process is undertaken to determine if a referral fits the relevant scope of the programme.

Referrals are screened based on programme requirements. Priorities determined based on country context and organizational capacity. Case Supervisor will assign a Case Manager to conduct the intake interview. If the child’s identity cannot be clearly identified, the benefit of doubt is given to the child

A suggested screening process is as follows:

  1. The Case Supervisor who receives the referral form will make a preliminary assessment as to whether the case falls within the scope of the organization’s programme based on the information in the referral form.

  2. Cases may be screened along the below criteria using the screening template in Annex 9a:

  3. Age in documentation – whether above or below 18 years

  4. Documentation status – whether undocumented or has some form of valid document that prevents arrest and detention

  5. Safety in the community placement or housing – whether stable or unstable care environment

  6. Location – whether within the area of the organization’s work

  7. Any other known vulnerabilities – whether he/she has experienced sexual or gender based violence (SGBV), a survivor of violence and/or torture (SVT), or has mental health issues or disabilities.

  8. The screening priority measurement below is based on the country context, community needs, and organizational capacity and resource. This priority scale should be adapted to fit the relevant organization and country context.

Priority Description Action taken
Screened out above 18 in official documents, documented, and in safe housing Client or referral agency informed that no further action will be undertaken until more documents are provided
Keep in View intake above 18 in official documents, undocumented and in unsafe housing Case Supervisor refers client for housing intervention pending further documentation 
Normal priority below 18, documented, in safe housing Case Supervisor schedules intake within three weeks of referral date
Urgent priority below 18, undocumented, in safe housing; or below 18, documented, in unsafe housing Case Supervisor schedules intake within seven days of the referral date with relevant housing intervention where necessary
Highest urgent priority below 18, undocumented, in unsafe housing Case Supervisor schedules intake within three days of referral date
Emergency priority below 18, undocumented, and at risk of abuse or exploitation Case Supervisor does an immediate intervention to ensure the safety of the child pending a full intake interview
  1. If a referral is assessed as being within the scope of the programme, the Case Supervisor will assign a Case Manager to conduct the intake interview to assess the vulnerabilities and immediate needs of the child.

  2. If the child’s identity cannot be clearly identified (e.g. lack of documentation to determine age or vulnerabilities), the benefit of doubt is given to the child, and the Case Manager proceeds to conduct an intake interview to obtain further information.

  3. In some circumstances, screening may also be done in detention centres. Depending on the capacity of the organization, the screening may prioritize the release of children based on the vulnerabilities present and feasibility of a case resolution or readily available community placement. A suggested screening tool is provided in Annex 9b.

7.3 Phase 3: Rapport Building and Intake Process

7.3.1 Rapport Building Process – The first meeting

Time is invested in engaging and building rapport with clients. A supportive and safe environment is created for the client. The surrounding environment should be suitable for interviews, and the client’s non-verbal cues and apprehension noted. Multiple visits should be scheduled, particularly for those who have experienced some trauma or abuse.

The client-case manager relationship is a dynamic relationship based on mutual trust and respect. Rapport building is an ongoing process for building trust, establishing common ground, demonstrating empathy and understanding, and opening up channels of communication throughout the lifecycle of a case. It is important for Case Managers to invest time in engaging and building rapport with their clients. Rapport building starts at the first meeting with the child. The following are some suggested methods to build rapport and some important things to keep in mind when you first engage with a child:

  1. Take time to create a supportive, safe and welcoming environment when you first meet the child.

  2. If you are just building rapport, do not collect any specific information at this stage, as the consent and confidentiality process has not been undertaken.

  3. Conversation topics during this phase may include an introduction to the Case Manager and the organization, general conversation about how the child is doing or his/her interests, answering questions or concerns of the child.

  4. Acknowledge the child’s anxiety and apprehension and try and create a safe, comfortable and open environment.

  5. Be present and listen to the child as he or she speaks.

  6. Acknowledge any biases you or the child may have towards each other – for example, gender biases where a female child might consider herself not as important to be heard as for a male child.

  7. Acknowledge any cultural differences or expectations that may impede communication and rapport building – for example, cultural differences in body language and tone.

  8. Manage expectations in your role while making the child feel comfortable and engaged in the process.

  9. For those children who have experienced trauma or abuse, multiple visits may be needed as part of this rapport building process. Make a note of your observations and consult your Case Supervisor to decide if follow up visits are needed to build trust and rapport. Hardcopies of these notes must be filed in the respective client folders for future reference.

Some key questions and things to pay attention to:

  1. Child’s surrounding environment - Is it suitable for future assessments or interviews?
  2. Non-verbal behaviour –How is the child responding to you?
  3. Interaction with people closest to the child (guardian, community member, referring agency) – Will rapport improve if an individual close to the child is present for the subsequent home visits?

7.3.2 Intake Process

Time is invested in engaging and building rapport with clients. A supportive and safe environment is created for the client. The surrounding environment should be suitable for interviews, and the client’s non-verbal cues and apprehension noted. Multiple visits should be scheduled, particularly for those who have experienced some trauma or abuse.

In the intake process, the interviewer will carry out an interview to identify a client’s needs, issues, strengths, challenges, and risks that will be useful for the assessment process. It is important that the interviewer captures all the information accurately and comprehensively to support the decision making and care planning process. Where necessary, the intake process may be carried out in the presence of persons that the child can trust.

The following is a suggested process framework:

  1. Once a child’s case has been assigned to a Case Manager, the Case Manager should arrange for an intake interview based on the priority timelines under Phase 2: screening process.

  2. Arrangements to decide on the date, time and place for the intake interview should be made depending on the circumstances of the case: either by contacting the agency or the person who made the referral, or the child, through an interpreter.

  3. Make arrangements for a suitable interpreter to be present during the intake interview. Ensure the venue is conducive and has adequate privacy.

  4. At the start of the interview, the Case Manager should do the following (as provided for in Annex 10):

    1. Explain the purpose of the visit or interview, the organization’s scope, and the general interview process.

    2. Explain the role of the Case Manager and the organizational decision-making process. Make sure you manage expectations about decision-making timelines and limitations in the organizations influencing the migration/refugee process.

    3. Address confidentiality concerns by highlighting how information will be shared and stored.

    4. Explain the right for a child not to answer questions he/she is not comfortable with and allow the child to ask any questions he or she may have.

  5. If the child seems nervous or uncomfortable, try to build rapport and make the child feel relaxed by attending to his or her immediate needs, such as offering a drink or a snack. Start by talking about positive or neutral topics, such as favourite things or interests.

  6. Ask the child for consent before proceeding with the interview. If the child does not consent for whatever reason, the interviewer will have to end the interview and reschedule once the child is ready to be interviewed.

  7. Use the Client Needs and Risks Intake Form (Annex 11) as a guide in conducting the interview. Fill in all the required information as you go along. Information on needs can be collected across pertinent life areas including: daily functioning and welfare needs, legal, educational, health, and psychosocial needs, the existence of any abuse or exploitation, and the child’s interests and life goals. The form provides an understanding of the needs, risks, and strengths of the client.

  8. It is important for the Case Manager to pay attention to both verbal and non-verbal responses, taking into consideration the cultural norms and barriers in communication, as well as observing the surrounding circumstances of the child. Ensure that the child has adequate opportunity to narrate his or her story or communicate his or her needs.

  9. The Client Needs and Risks Intake Form provide guiding questions to be used at your discretion, depending on the openness of the child and the level at which trust and rapport has been built. Where the child is not comfortable responding, move on to the next question taking note of the non-verbal cues.

  10. Any urgent need disclosed during the intake interview must be addressed by the end of the interview. For example, if safety in housing is a concern the Case Manager may need to contact relevant agencies or organizations for a child at high risk to be placed in a temporary shelter, if necessary.

  11. The Case Manager may also need to schedule and conduct interviews with other persons in the child’s life to obtain additional or corroborative information to note down in the Client Needs and Risks Intake Form.

  12. Once the interview is completed, thank the child for his or her time and for sharing his or her story with you. Manage expectations that a decision on admission into the Programme will take some time, and inform the child that you will be contacting him or her after a decision has been made.

  13. Hardcopies of all intake forms and notes must be stored in the relevant client folders in the organization’s office, and scanned copies of these forms must be stored on the cloud server. Information from these documents should be kept confidential.

7.4 Phase 4: Assessment Process

Information gathered during the intake process is used by the Case Committee to assess a case. Decisions are made based on weighing the needs, risks, and protective factors of a case in the best interest of a child. Goals are also suggested to assist the Case Managers with the Care Planning phase. This phase should be completed within four weeks of the intake.

The assessment process involves the Case Committee making an assessment on the case based on the information gathered during the intake phase. The Case Committee will engage in a rigorous and detailed analysis of information to determine support that will be in the best interest of the child. Decisions made during this phase will be used to effect phase 5 of the case management process. The following is a suggested process framework:

  1. The organization will appoint members to be in the Case Committee, who will assess cases presented for admission and review. Members of the Case Committee should, at the very minimum, include the Case Managers, Case Supervisor, Project Director, and an independent advisor.

  2. Prior to the Case Conference being scheduled, the Case Manager is expected to do the following:

  3. Complete the Heightened Risk Rating Form (Annex 12) to determine the child’s current level of risk. Risk assessment should include both risk and protective factors for the child. Areas of potential risk include future housing, possible caregiver relationship, legal status, past abuse or exploitation, and any physical or mental health concerns, amongst others.

  4. Complete the Programme Admission Form (Annex 13) based on information gathered during the intake phase and noted on the heightened risk rating form.

  5. Complete the Child Trauma Screening Questionnaire (Annex 14). The 10-item self-report screening tool may be used to identify children at risk of developing post-traumatic stress following a particularly traumatic event, such as immigration detention, flight from the country of origin, recent persecution in the country of origin, etc. The tool will assist Case Managers in developing the necessary intervention plan to address the risk of post-traumatic stress.

  6. Once documentation is completed, the Case Manager will schedule for a Case Conference with the Case Committee. The completed documentation will be given to the members of the Case Committee before the scheduled Case Conference.

  7. During the Case Conference, the Case Manager will present the case along with relevant recommendations. The Case Committee will thoroughly deliberate, weighing organization capacity and resources, and the risk and protective factors for the child.

  8. A decision is then made as to whether the child should be provided with case management support, the time period for support, and key interventions to be carried out. The Case Committee also decides on a suitable community placement option for the child (i.e. if he or she should be placed in foster care or provided with other forms of intervention).

  9. Decisions made will be documented on page 1 of the Programme Admission Form (Annex 13) and signed off by the Case Supervisor. This document will be used to assist the Case Managers during the care planning phase. This document will also be used when reviewing the case during a monthly case meeting.

  10. Decisions must be made on a case by case basis after considering the child’s risk and protective factors. Clear justification for decisions made and the timelines for interventions and next steps must be written down to guide Case Managers.

  11. The child has the option of appealing a decision by the Case Committee by filling in the Admission Appeal Form (Annex 42), which will be submitted to an independent assessor appointed by the organization. Any decision made by the assessor is final.

  12. Hardcopies of all assessment forms must be stored in the relevant client folders in the organization’s office, and scanned copies of these forms must be stored on the cloud server. Information from these assessments should be kept confidential.

  13. The assessment phase should be completed within four weeks of the intake for non-emergency cases.

In some cases, a child may not be suited for the full case management programme or may be screened out because he/she may not fit the programme criteria.

In such cases, the organization should be open to solving specific needs of a child, where possible. Specific and time-bound interventions may still be carried out to ensure, at the very least, that the child is safe and not at risk of arrest and detention.

Examples where case management may not be appropriate include when the child is above 17 years old, when age cannot be gauged properly, when a child is unwilling to voluntarily cooperate with the programme requirements or when a child is a separated minor in safe care arrangements.

7.5 Phase 5: Rapport Building and Care Planning

7.5.1 Rapport Building

If the assigned Case Manager did not conduct the intake interview, the first point of contact with the child will be during this Phase. Rapport building will therefore begin at this phase. Suggested methods to build rapport discussed in Phase 3 will similarly apply here.

Rapport building will also continue throughout the lifecycle of the case. Taking time to maintain rapport is important to ensure a child’s continuous engagement and compliance in the case management process. If there is no rapport, it can result in the child absconding or disappearing, a lack of trust between the Case Manager and the client, non-compliance with programme requirements, and challenges in meeting care plan goals. Though not an exhaustive list, below are suggested methods to continue to build rapport and engagement with the client:

  1. Continue to create a trusting environment and relationship with your client. Ways to do so would be to respect confidentiality and only share information with others on a needs basis and as agreed by your client.

  2. Respond to queries or messages from the child in a prompt manner. A response to say you will get back to him or her as soon as possible would show that you place importance on his or her needs.

  3. Keep scheduled appointments and arrive on time for appointments with the child as this shows you are respecting his or her needs and time. If you are unable to attend an appointment because of an emergency, apologize and inform the child promptly.

  4. Respond to emergencies as soon as possible, and when doing so, be empathetic and mindful of the child’s fears and concerns.

  5. Be empathetic and present for the child when he/she is going through difficult appointments or challenges in life.

  6. Listen to the child to keep him/her engaged throughout the process.

  7. Avoid making decisions for the child, but instead, engage in a decision making process by jointly weighing the pros and cons, and empowering him or her to decide for himself/herself. This will, of course, be dependent on the age and maturity of the child.

  8. Regularly conduct checks with the child to maintain contact. This helps the child know that there is someone looking out for him or her. When you are away, make arrangements for other Case Managers or volunteers to check-in with the child.

  9. Keep yourself updated and remember important appointments (such as migration related appointments), and follow up with the child on the outcome of these appointments.

  10. Finally, extend wishes to the child during religious, cultural days, or birthdays to show that you are aware of his or her beliefs and practices and that he/she is important.

7.5.2 Care Planning

Care Planning is a multifaceted process, which ties in the relevant goals and needs of the client with a holistic intervention plan. Care plans are client centred and may be developed after several meetings or visits with the child, and in close discussion with caregivers, the Case Supervisor and other Case Managers. The care plan will include:

  1. Identified needs or risks.

  2. Specific client goals to address these needs or risks.

  3. Strategies or an action plan to achieve these goals.

  4. Agreed timeframes to undertake the action plan.

  5. Clearly assigned tasks or referral processes based on the timeframes.

  6. Clearly specified outcomes and results.

Regular reassessments should be built into the care plan to adapt to changing circumstances and to track progress of the goal attainments.

A suggested process in the care planning phase is as follows:

  1. Case Managers will schedule a meeting with the client to inform him/her of the organization’s decision and will obtain consent for participation in the programme.

  2. As the client is a minor, consent will need to be obtained from the parent, guardian or caregiver, where possible, and from the child. A sample of the relevant consent forms are included in Annex 15and Annex 16.

  3. During this phase, Case Managers must:

  4. Explain the decision, and respond to any questions a child may have with regards to the decision.

  5. Clearly explain the scope of the programme or services that are to be provided, based on the decision made by the organization.

  6. Explain the role of the child and Case Manager throughout the process.

  7. Provide information on the complaints mechanism, should the child be unhappy with the services provided by the Case Manager.

  8. A hardcopy information pack with detailed information on the above processes should be provided to the child.

  9. Hardcopies of consent forms must be stored in the relevant client folders in the organization’s office. Scanned copies of these forms must be stored on the cloud server.

  10. Once consent has been obtained, and the child fully understands his or her rights and the case management process, the care planning process may be initiated. The Case Manager will engage with the child to develop and agree on goals, strategies, outcomes and timeframes. As a Case Manager, ensure that goals, strategies, outcomes and timeframes are Specific, Measurable, Achievable, Realistic, and Time bound. This exercise will be carried out using the Full Client Individualized Care Plan Template in Annex 17 and Annex 18.

  11. The Care Plan Template is to be cooperatively filled by the Case Manager and the client with both parties agreeing on the goals, strategies, outcomes, timelines and responsibilities. Each goal and action will be specific to the child. Once the goals are agreed on, they will be written down and a copy of this form will be given to the child.

  12. The Care Plan must also provide all relevant details of referral services that will need to be utilized by the child, and list persons responsible for engaging these referral service providers. The Care Plan will also be adapted and changed in Phase 6 and 7, depending on the child’s progress and the relevant monitoring and reassessments exercises.

  13. If the child has been placed with a foster family, this care planning exercise is undertaken with the foster parents. The Case Manager will work with the foster parents and the child to design and implement a care plan for the placement. A copy of the care plan will also be given to the foster parents.

  14. Once the care plan has been developed, it must be reviewed by the Supervisor within two weeks. The supervisor may provide input on the accuracy and suitability of the care plan.

  15. All information obtained here will be stored in a similarly secure manner as stated above, in hard and soft copy formats.

  16. The individualized care plan should ideally be completed within 14 days6 of the completion of Phase 4 and will continue to be reassessed or updated throughout Phase 6 and 7.

  17. A sample completed Care Plan is provided in Annex 19.

7.6 Phase 6: Implementation of the Care Plan or the Intervention Phase

Upon collectively planning the individualized care plan with the child using Annex 18, the intervention plan should now be initiated based on the agreed strategies and timelines.

When implementing the care plan, a Case Manager should:

  1. Be proactive, action-and-solution-oriented, working with the child’s strengths and empowering the child through a partnership process to attain goals and case resolution.

  2. Implement care plan actions and strategies at the appropriate times to achieve goals.

  3. Be flexible and able to adapt care plans or re-strategize based on internal and external variables.

  4. Identify and explore creative options for referrals to achieve care plan actions.

  5. Coordinate direct and indirect services for the child.

  6. Collaborate and actively build relationships with referral agencies to increase efficacy in achieving care plan goals. Ensure that all relevant agencies are aware of each other’s involvement in assisting the child through the process.

  7. Maintain open communication with all stakeholders and ensure documentation of all communication and suitable sharing of information or reporting.

  8. Ensure that the child understands and is always aware of any changes in the care plan or referral agencies.

It is recommended that timelines for the implementation of interventions and referrals be clearly identified in the care plan during Phase 5. Adjustments can be made to the care plan, when necessary, and in consultation with the client.

7.6.1 Coordination of Referrals with Service Providers

The main role of the Case Manager in the implementing phase is the coordination of services and referrals for the client to ensure that the child’s needs are addressed. The Case Manager is expected to identify, communicate with, and follow up with all referral agencies on a regular basis.

A recommended process to coordinate referrals to service providers is as follows:

  1. Identify the service provider based on the needs in the care plan and, also, the location of the child.

  2. If a child is already accessing services with a service provider, check the services the child is provided to avoid the duplication of resources.

  3. Once gaps and relevant service providers are identified, contact the service provider or individual by telephone or email to ascertain if the agency or individual is able to provide the relevant services for the child.

  4. If the service provider has a referral form, complete the referral form. If the service provider does not have a referral form, use Annex 20.

  5. Confirm appointment time and availability of an interpreter with the service provider by telephone or email.

  6. During the first visit, accompany the child, providing any case notes or any other information that the child has consented to sharing to ensure that the service provider is able to provide the best care.

  7. Following the first visit, keep in constant communication with the service provider and follow up on the child’s progress.

  8. Reports of this progress must be clearly documented. All documentation from the referral process must be stored in a similarly secure manner as stated before, in hard and soft copy formats.

7.6.2 Implementing Interventions

Interventions carried out will differ based on the needs of the child and goals of the case management. More detailed intervention plans may be developed for a specific need and further assessments may be needed. Potential needs of a child based on the case management goals that may require intervention include:

A suggested process framework for each need is provided below.

7.6.3 Safety: Protection from Abuse, Maltreatment and Neglect

A child is in present danger when there is an immediate, significant, and clearly observable threat actively occurring in the present time. Danger or safety threats include any real or risk of physical, sexual, verbal maltreatment, abuse and neglect.7 A child is in imminent danger when there are conditions that are not actively occurring or clearly observable but are likely to cause serious harm to a child in the near future. For imminent danger, the harm is likely in the near future (not exceeding 60 days),8 and if no intervention is carried out.

A core intervention process will therefore include ensuring that a child in out-of-home care is always safe from abuse, maltreatment and neglect.

The following suggested process should be carried out to determine if a child is safe in out-of-home care:

  1. Conduct regular monthly checks with the child to talk about the home environment and placement.

  2. Conduct interviews with the caregiver or persons in current placement to periodically assess the home safety situation.

  3. Home visits should be conducted on a monthly basis. During this time, observe the non-verbal interactions between the child and others in the home.

  4. A risk and safety assessment of out-of-home care must be conducted for every new placement.

  5. A best interest assessment should be conducted after 12 weeks9 in a new placement.

If a child is deemed to be in present danger, the following is a suggested framework:

  1. Clearly document the threat or danger and determine if the child needs medical attention.

  2. If the child requires medical attention, immediately seek treatment at the Emergency Department of the nearest hospital.

  3. Find alternative places for the child to stay for the next 72 hours.10

  4. Make arrangements for the child to move and remove the child from the unsafe environment to a temporary safe place pending full assessment.

  5. Call for a discussion with the Case Supervisor, or if time permits, call for an emergency Case Conference with the Case Committee.

  6. Following the case discussion, carry out relevant interventions which may include: making a police report or informing relevant authorities, finding new alternative care arrangements, and referring the child for further health interventions and psychological assistance.

If a child is deemed to be in imminent danger, the following is a suggested framework:

  1. Clearly document the threat as soon as possible..

  2. Discuss the case at a Case Conference. A decision should be made as to whether the child should be removed from the environment, for suitable recommendations for alternative placement, and for relevant timelines for the move.

  3. Identify and screen a suitable alternative care arrangement, preferably a foster care arrangement, within seven days11 of the Case Conference.

  4. Ensure that the child’s opinion is sought before any move to a care placement is made.

  5. Make arrangements for the child to move within 30 days of the first identification of the threat.

  6. Develop a safety plan with the child and new caregiver (Annex 21).

  7. Periodically follow up with home visits at this new placement to ensure that the child is adjusting well.

  8. Carry out any other relevant interventions which may include referring the child for further health interventions, psychological assistance, if necessary, and equipping the child with the necessary skills to protect him or herself.

7.6.5 Stability and Permanency: Alternative Placement of Care

Where family reunification is not possible (such as where a child has escaped from his/her caregivers or country of origin due to safety issues), or is unsuccessful, intervention will include securing an alternative placement of care in the community. In each of these cases, explore the following community placement options in the following order:

  1. Firstly, guardianship and kinship care by relatives or close family members in the community. This is usually often already being done in some form in the community and the monitoring of this relationship is needed to ensure that the placement is safe.

  2. If there is no relative to care for the child, then consider placement in foster care arrangements by other community members. A separate section (page 65 onwards) in this Manual provides guidance on the processes on identifying, matching and placing a child in such care arrangements.

  3. If options for placement with a relative or in foster care arrangements are unsuccessful, older children may be placed in independent living group homes. An assessment needs to be undertaken to determine which children should be placed in these peer-headed households. More support and supervision by the Case Managers will be required for this arrangement. House rules will also need to be developed and agreed on by the children living in the household. A sample is provided in Annex 23.

  4. When community placement and independent living is not possible due to safety reasons, the final option for alternative care for a child may be a shelter or residential care placement. This placement option should ideally be temporary, pending more permanent solutions on care arrangements being developed.

7.6.7 Stability and Permanency: Longer-term Durable Solutions

Depending on the country context and legal status of the child, longer term options may include:

  1. Resettlement for refugee and asylum seeking children.

  2. Repatriation home following family reunification and/or when it is safe for a return.

  3. Preparation to live independently when a child turns 18 and ages out of the case management programme.

To determine suitable options, a best interest determination should be carried out, weighing the circumstances and the wishes of the child. Development of longer term solutions must be planned in consultation with the child.

7.6.8 Child Well-being: Material Well-being

A key intervention would be ensuring that a child’s material needs are adequately attended to following community placement. These needs may include: food, clothing, shoes, sanitary and hygiene items, and bedding. The provision may be one-off or on a regular or monthly basis. A suggested process framework may be as follows:

  1. Identify the material needs of the child during the intake and care planning phase.

  2. Identify relevant service providers to meet those needs or source relevant items to be provided by the organization.

  3. Identify the amount and period of provision. Ensure all items are in good condition and meets the needs and religious or cultural preference of the child.

  4. All food provided must be nutritious, suitable for consumption and in line with the child’s cultural, religious and other dietary needs.

  5. Regularly deliver relevant items to the child when necessary and without delays.

  6. Regularly follow up on the material needs of the child.

7.6.9 Child Well-being: Physical Health

Based on the health needs identified during the intake phase, an appropriate intervention plan should be developed to address these and any other physical health needs of a client. In general, interventions should ensure a child is healthy and has adequate access to health care services. The following processes are recommended:

  1. Identify past or current physical health needs of the client during intake. A sample physical health assessment checklist is also provided in Annex 24.

  2. Refer the client to relevant healthcare services for a general health check to identify health needs or to confirm a particular health issue.

  3. Follow up on the recommended intervention plan from the healthcare professional, including specialized follow up treatment or tests, when necessary.

  4. Ensure there is sufficient financial means to implement the recommended intervention plan.

  5. Clearly document and ensure continuous monitoring of treatment and follow up visits until the health concern is resolved.

  6. Where necessary, a treatment and medication plan should be developed and updated accordingly with the child (see Annex 25).

7.6.10 Child Well-being: Emotional and Mental Health

Based on mental health needs identified during intake, appropriate intervention plans should be developed to assist the child in achieving stable mental and emotional health. The following processes may be initiated:

  1. Refer the child for a general mental health assessment by a mental health professional.

  2. Develop an intervention plan based on the recommendations from the mental health professional.

  3. Obtain consent from the child before any assessment or treatment is carried out.

  4. Follow up on all necessary counselling or therapy sessions and prescribed treatment, including any specialized tests or assessments, as needed.

  5. Ensure continuous monitoring of the child’s mental health and documentation of follow up visits for therapy, where necessary.

  6. Encourage the child to participate in regular or periodic age appropriate psychosocial activities carried out by the community or other service providers.

7.6.11 Child Well-being: Education

The intervention plan should ensure that a child has adequate access to formal or informal educational opportunities and other skills-based learning to prepare the child for independent living. Educational opportunities should be in line with the age and developmental level of the child. A suggested process framework may be as follows:

  1. Identify relevant service providers located near the child who is able to provide educational services that meets the child developmental level.

  2. Refer and liaise with a relevant educational centre for enrolment. A sample intervention referral form is provided in Annex 20.

  3. Ensure the child has all relevant items to attend school, such as books, stationery, school uniform set, etc.

  4. Regularly follow up on the child’s progress in school and seek help from teachers and the foster parents or caregivers to assist as well with the follow up.

  5. Where no educational opportunities are readily available, be proactive and engage volunteers or set up an independent programme for the child to learn, at the very least, English and Mathematics.

7.6.12 Child Well-being: Adequate Housing

A child must have a safe and suitable place to stay. A suggested process framework to ensure a child has appropriate housing is as follows:

  1. Conduct a risk and safety assessment of the house and the surrounding environment as per the checklist in Annex 26 to determine if the housing is suitable.

  2. Where necessary, work with the caregivers and foster parents to ensure that the housing and living conditions are adequate for the child.

  3. A safety plan should be developed with the foster parents or caregiver, and the child (seeAnnex 21).

  4. In situations where efforts have been made to improve conditions, but the housing conditions still are below minimum standards, determine if it is in the best interest of the child to be moved to a more appropriate housing and living condition.

7.6.13 Child Well-being: Relationships and Support Systems

Ensuring that the child has a strong support system and positive relationships is integral in meeting well-being goals. Suggested initiatives include:

  1. Identify the positive support systems and relationships in the child’s life.

  2. Encourage the child to build or develop these support systems.

  3. If there is no support system, identify and refer the child to support groups and community groups that can be a support for the child.

  4. Conduct three interaction activities a year for the children in the programme to foster relationships and to build a support system among the children in the programme.

7.6.14 Child Well-being: Risk and Safety

This goal focuses on the risk and safety of the child at the hands of the State and non-State actors as a result of the child’s legal status and reason for leaving his or her country of origin. This goal is different from the first goal of safety as it focuses more on the arrest, detention and community violence against the child rather than safety within a caregiver or housing situation. As such, based on the needs of the child, interventions may be needed to address the risks and safety of the child with regards to the risk of victimization or threat of violence in the community, and/or incidences of arrest by the authorities. A safety plan should be developed with the foster parents or caregiver and the child in case of such risks (similar to the section on Adequate Housing above).

  1. Conduct a risk and safety assessment of the community and surrounding area. Identify all potential risks and threat of harm in the child’s life.

  2. Develop a safety plan with the caregivers or foster parents to mitigate the risks.

  3. Where efforts have been made to mitigate risk but the threat of harm is still present, a review of the current placement is to be conducted. Consideration should be made as to whether a child will need to be moved to a safer location because of the threat of harm.

7.7 Phase 7: Monitoring and Reassessment

Monitoring and reassessments of care plans are carried out with the child’s help to identify the progress in achieving goals, the efficacy of interventions, the priorities, and the necessary next steps. Monitoring is an ongoing and active process that constantly helps to inform the child, Case Manager, foster parents or caregivers, service providers, and other implementing agencies about the progress, gaps and areas for change. The monitoring and reassessments process may be case specific; however a general suggested monitoring framework is as follows during a case cycle:13

Case Manager checks with the child Team Case Review[^14]
[^14]: The team here usually involves Case Managers and the Case Supervisor.
When the Case Supervisor is not available, the Project Director assists.

    Case Committee Review
1-12 weeks (1st-3rd month) bi-weekly once in three weeks once a month
13-36 weeks (4th–9th month) monthly monthly once in two months
37 weeks onwards (10th month onwards) monthly initially monthly; subsequently, once in three months
6 months before termination monthly monthly once in two months
Post termination follow up for 6 months monthly once in three months once in three months


A suggested process framework is as follows:

  1. During the first 12 weeks of admission of a case, Case Managers should monitor the case and the community placement on a bi-weekly basis.

  2. Any new community placement should also be monitored on a bi-weekly basis for 12 weeks. A monitoring checklist is provided in Annex 27. After the 12 weeks, a best interest assessment should be conducted on the placement.

  3. Following a case stabilizing (usually after three months), Case Managers should conduct monthly home visits and checks to review the care plan. During these home visits or checks, Case Managers should follow up on progress of the care plan, as well as investigate any other new issue pertaining to the case management goals (see Annex 27 and Annex 28).

  4. If a child is placed with foster parents, Case Managers should also meet the foster parents to discuss any issues pertaining to the child’s care plan, personal development and the foster care arrangement.

  5. Team Case Review meetings should be conducted with Case Managers and the Case Supervisor to review each care plan. A monitoring review will determine the following:

  6. Whether care plan goals remain relevant.

  7. Whether the care plan and list of service providers are meeting the needs of the child.

  8. Whether there are any changes to the child’s situation or environment.

  9. Whether interventions have aided goals achievement, and the impact of these goal achievements.

  10. Whether strategies are adequately resourced and all partners are contributing towards the goal achievement.

  11. Whether Case Managers are complying with timelines in implementing the care plan.

  12. Whether the child is cooperating in carrying out the care plan.

  13. Case Committee Reviews must also be carried out via the Case Conference method. The Case Committee will review a child’s progress or the barriers to the attainment of goals, the Case Managers’ conduct and interventions, conflict or crises resolutions, and identify solutions for any concerns raised in managing a case. Case conference discussion and related decisions are documented in the form in Annex 13.

  14. Case Managers must ensure that monitoring and reassessment documentation is accurate and up-to-date. Case progress should be documented usingAnnex 27 and Annex 28. Furthermore, the last two columns in the Full Client Individualized Care Plan Template (Annex 17) provides for the collection of information under this monitoring exercise. Where goals and strategies are reassessed, the Case Manager, client (and where necessary, the foster parents), will jointly develop a new care plan.

7.8 Phase 8: Termination and Case Resolution

Termination of a case may occur under one or more of the following circumstances:

  • A durable solution is achieved (voluntary repatriation or resettlement).

  • Family reunification.

  • Aging out upon the client turning 18 (subjected to the relevant transition process).

  • The client voluntarily terminates.

  • Termination by the organization.

  • Upon death of the client.

In instances where contact is lost with the child, the case remains inactive with the possibility of being re-opened once contact is made. The case will only be automatically closed six months later or sooner where information on termination is received.

In all cases of termination, the following should be carried out:

  1. A client exit process form (using Annex 29) is completed with the child and/or caregiver or foster parents before the case is officially closed.

  2. A client feedback form (Annex 30) is completed.

  3. An exit letter or termination letter is issued, and, in some instances, a recommendation letter (samples in Annex 31 and Annex 32) is completed to assist the child with future endeavours.

  4. A final debriefing between the Case Manager and the child is carried out. In some cases, this debriefing is also done with the foster parent.

  5. A debriefing between the Case Manager, Case Supervisor and Project Director is conducted and the necessary documentation or case notes should be completed for reporting.

7.8.1 Durable Solution (Resettlement or Repatriation)

  1. Liaise with the relevant agencies involved, such as the relevant embassies, UNHCR and IOM.

  2. Assist the child to prepare for resettlement or repatriation in any way deemed necessary, such as providing recommendation letters that may be helpful for the child to get a job or attend school in the new country, obtaining clothing for the child that is suitable for the new climate or travel luggage for the child to pack his/her belongings.

  3. For a child who is being resettled, enrolment in language classes may be needed if he/she does not yet speak the country’s language.

  4. For a child who is being repatriated, ensure that the repatriation is carried out in a child friendly manner that avoids exploitation and the risk of trafficking.

7.8.2 Family Reunification

In some situations, the child’s immediate family members may have arrived in the country after the child is in the programme, or there may be successful tracing and family reunification following a separation from the family unit in the country. The following are relevant processes to be initiated following such situations:

  1. Following successful tracing and family reunification intervention (highlighted above under Phase 6), assist the child with the transfer to stay with the family.

  2. Continue to monitor the placement on a monthly basis for six months to ensure it is in the best interest of the child to live with the family.

  3. Support the child’s family to care for the child by referring the family to relevant service providers who can help address their needs.

7.8.3 Aging out

In instances where a child reaches the age of 18 but has no other durable solution, a transition phase will be initiated to prepare the child to exit from the programme. This transition phase ensures that a child is ready to exit the programme as all the needs currently being addressed via case management should be taken care of without case management interventions when the child exits. To prepare a child to exit the programme, these interventions may be initiated:

  1. Provision of English classes and other skills based or vocational training classes to prepare the client for job placement.

  2. Securing suitable job placements for the client, or developing sponsorship programmes for the client when he/she is unable to work or provide for him or herself.

  3. Preparing the client to leave foster care arrangements by obtaining alternative housing and learning skills to live independently.

Once a client turns 18 the following is initiated:

  1. A six-month transition phase where the client continues to be assisted to become self-sufficient.

  2. Following this transition phase, a review will be conducted by the Case Committee to ascertain if termination is possible or an extension of the phase is needed.

  3. Once termination is recommended, a three-month and six-month frequency of follow up will be undertaken to ensure that the client is still safe and adjusting well in the community.

7.8.4 Client voluntary termination

In some situations, the child may decide to leave the programme before case resolution is reached. The following should be carried out when a child expresses the wish to exit the programme:

  1. Organise a meeting with the child to understand the situation better.

  2. The child’s situation is reviewed at a Case Conference to determine if termination is in the best interest of the child.

  3. If it has been agreed for the child to leave the programme, inform the foster parents of the decision and the plan to help the child transition out of foster care.

  4. Refer the child to speak to a counsellor or psychologist, where necessary, to help with the transition or to address any concerns.

  5. If the decision is that it is not in the best interest of the child to exit the programme, advise the child accordingly, explaining why it is not in the child’s best interest to do so.

  6. Review the care plan and develop new interventions to address the concern that it is not in the best interest of the child to exit the programme.

  7. Make arrangements for the child to speak to a counsellor or psychologist to help him/her understand this decision and work through any underlying issues.

  8. If the child is adamant on leaving despite the decision, respect the decision to leave, but continue to monitor the child’s situation to ensure safety for the child.

  9. The child should be given the option to re-enter the programme within three months from termination if the child changes his/her mind about termination.

7.8.5 Termination by the organization

In some situations, the organization may determine that it is no longer in the best interest of the child to be in the programme. In such situations, it is important the following is carried out:

  1. Ensure that the decision to terminate has been reached unanimously at a Case Conference meeting after weighing the impact of the decision and withdrawal of services on the child.

  2. Inform the child promptly of this decision and develop a transition plan for the child to exit the programme.

  3. Inform the child’s foster parents of the same decision, if the child had been placed in foster care.

  4. Provide the child with the opportunity to appeal the decision in writing. An appeal must be reviewed by different Case Committee members in a fair and objective manner.

  5. If the decision to terminate remains, make arrangements for the child to transition out, similar to the Aging out process stated above.

7.8.6 Upon the death of the child

If, due to some unforeseen circumstances, the child dies during his or her placement in the programme, the following should be initiated:

  1. Report to the authorities of the death with the relevant details.

  2. Cooperate with the authorities on any investigations conducted, if needed.

  3. Report the death to the child’s next of kin.

  4. Conduct an internal review and investigation on the circumstances of the death and review necessary protocols and procedures to avoid a similar unfortunate situation.

  5. Arrange for the child’s burial, based on the family’s wishes and cultural or religious preference of the child.

  6. Debrief with the other children in the programme and the foster parents of that child.

  7. Debrief with the Case Manager, Case Supervisor and Project Director on the loss. Complete relevant documentation and incident reports accordingly.

  8. Refer a counsellor or psychologist to help all persons in the child’s life to deal with the loss.


  1. The following timeline is organizational specific based on current capacities and practices. Organizations should adapt timelines to fit their context and needs.↩︎

  2. Adapted from UNHCR, Heightened Risk Identification Tool, version 2. Available at: http://www.unhcr.org/refworld/docid/4c46c6860.html.↩︎

  3. Timelines adapted from UNHCR, Heightened Risk Identification Tool, version 2. Available at: http://www.unhcr.org/refworld/docid/4c46c6860.html.↩︎

  4. Adapted from the Field Handbook for the implementation of UNHCR BID Guidelines. Available at: www.unhcr.org/50f6d27f9.pdf.↩︎

  5. Timelines adapted from UNHCR, Heightened Risk Identification Tool, version 2. Available at: http://www.unhcr.org/refworld/docid/4c46c6860.html.↩︎

  6. Timelines are based on organizational context and capacity. Organizations should adapt timelines accordingly to fit context and needs.↩︎

  7. Available at: https://www.icrc.org/eng/assets/files/other/icrc_002_1011.pdf.↩︎

  8. The monitoring framework which is suggested is based on the current organizational practice and complexities of the case. Organizations should develop a framework best suited to their needs.↩︎