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Watch the video on a simulated client case provided then write an assessment according to section listed below:
Identifying Information: includes any relevant information that helps describe the client/client system such as name, age, gender, race, number of people in household and relationship to client. It should not include irrelevant information such as the client is attractive/the client is not very attractive. Consideration should be given as to what is needed in the file in order to identify the client and describe their concern versus unnecessary information. The writer should ask: If this information is included could it negatively impact the client? If it is not included will the description of the client be so incomplete it will affect accurate assessment and treatment? Is there a way to strike a balance between providing the needed information and protecting client privacy?
Referral Source and Presenting Concern(s):
Who referred the client?
What precipitated the contact? (Ex. “Client was referred by Department of Children and Families for mandated counseling after an investigation was performed regarding a report of physical abuse.” Or, “The client was referred by her/his medical doctor to address stress management.”)
What does the client perceive as the problem/concern?
What is the duration, frequency, severity of the problem/concern?
Psychosocial History Includes:
Family System: Names, ages, race, marital status of immediate family members and other significant and intimate members of the family system; roles, rules, relationships, dynamics.
History: Any relevant history of the client/family that may affect the current condition/situation.
Biological/Health/Medical Complaints/Concerns: Are there any medical conditions, physical complaints and/or health concerns for the client or the client’s immediate family members that may contribute to the problem? Example: Is the client a caregiver for an ill family member and does this increase the stress for the client? Is the client suffering from a medical condition that affects their functioning? Is the client overweight/underweight and does this present as a concern for the client? Is there a decrease in sexual functioning? Fatigue
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
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