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Part II. Watch the video on a simulated client case provided then write an assessment according to section listed below. Part 1 of this Assignment is attached.
Current Psychosocial Functioning Includes:
Cognitive, Affective and Behavioral Functioning:
Reality orientation-is the person oriented to time/place/person?
Judgment- does the client have the capacity to judge the effect of their decisions? Memory, intelligence
Appearance- this includes whether the client appears unkempt, disheveled, oddly dressed- (long, thick sweater in 100% heat), not whether the worker thinks the client looks good. It is appropriate to make statements such as, the client attended the interview professionally dressed, or the children were appropriately dressed for the weather, or the client appeared disheveled- hair appeared uncombed, clothes were tattered and dirty. Be careful to consider culture and normal bathing/clothing expectations. In some cultures, it is normal to wear the same clothes more than once a week or several days in a row and this does not indicate poverty or being unclean.
Behavior Patterns- note behavioral changes observed in sessions or reported by the client.
Affect/expressiveness- what are their facial expressions? Does the client appear to have facial expressions that are congruent to their stated mood and what they are reporting? Or do they seem to have inappropriate affect- facial expressions that do not match the content of their statements or their stated mood? Again, consider culture here. In some cultures, showing emotion is not appropriate.
Self-esteem- how does the client talk about self?
Fatigue, concentration, thought content, suicidal ideation, social skills, and communication patterns
Environmental Factors: Type of residence, length of time in that residence, neighborhood, living conditions, size, utilities, furnishings
Systems: Work, judicial systems, extended family members, other social agencies. Include only relevant systems and how they affect client, social policy issues affecting client, cultural implications.
Challenges /Resources/Strengths: Income, health insurance, employment, education, training, transportation, support system, religious affiliation or supportive belief system, other agency involvement, motivation, coping skills, attitude toward change, perseverance, assertiveness, quality of relationships to others, openness, insight, self-control, resourcefulness, life goals
Multidimensional Assessment Summary: This is a written professional summary of problems identified, needs or deficits of client/client system, along with existing strengths and resources to address those problems, needs, or deficits. Generally, this summary assessment should address the purpose of the initial referral. It is usually a paragraph, focusing on more global observations than details. It is a professional hypothesis based on the observations made by the worker. It is not a DSM diagnosis. It should not repeat already recorded information. This statement should be a deduction made regarding the client’s concerns based on the information gathered and the worker’s professional judgment, (knowledge, skills, and experience based on professional standards and ethical/legal guidelines.)
Plan: Plans for future contacts between the worker and client; plans for referrals, homework assignments. Always specify who will do what.
Presented information in an organized fashion, following recommended headings and format Included relevant client information, avoided excessive detail Avoided redundancy and repetition Summarized information succinctly and accurately in the Multidimensional Assessment section
Avoided grammatical and punctuation errors Used appropriate word choices, sentence structure, and professional tone Expressed ideas clearly and avoided ambiguity
Displayed objectivity in presentation, avoided value-laden words and judgments Demonstrated understanding of and adherence to social work values and ethics
Demonstrated insight about client behaviors and situation Effectively utilized relevant data to support professional interpretation and assessment Identified and distinguished objective information from subjective interpretations and opinions Plan follows the assessment appropriately Addressed points in final summary thoroughly and demonstrated insight
Link to simulated case video
Refection on Assignment
Personal values & challenges (We all have values and biases. Please thoroughly explore yours.)
Describe your initial reaction to the client and the issues.
Describe your personal biases related to this case.
Describe how your personal values might be challenged and how you will manage these challenges.
Address any ethical and/or legal issues in your work with this client. What are the potential legal and ethical concerns for this client? How will you respond?
Reflection (Be thoughtful and thorough in your reflection.)
What did you learn from this assignment?
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