Basic Information
Identifying Information (This includes: Client name, Gender, Age, Marital Status, Race, ethnicity, and nationality (if not born in the U.S.), Language spoken, Socioeconomic status, and current living arrangements (e.g., alone in an apartment with 2 flights of stairs to walk up, with children, etc).
Referral (How did you hear about this client?)
Presenting Problem (What specifically was the client referred to you for, then what the client thinks the problem is)
Sources of Data (Who is providing the information to you?)
General Description of Client
Background and Current Functioning
Family Composition and Background
Educational Background
Employment and Vocational Skills
Religious/Spiritual Involvement
Physical Functioning, Health Conditions, and Medical Background
Include physical/behavioral observations: physical appearance, grooming, indications of organic problems, mood, and/or unusual habits
Psychological and Psychiatric Functioning and Background
Include any previous treatment or diagnoses (that may not seem to relate to current CID)
History of trauma: abuse, violence, substance abuse, traumatic losses, etc.
Social, Community, and Recreational Activities
Legal Concerns and/or Financial Concerns
Other Environmental or Psychosocial Factors
Client Strengths, Capacities, and Resources
Impressions, Assessment, and Recommendations Note: In this section, you pull together the descriptive data on the client’s life and situation that you presented in your psychosocial assessment into a critical analysis of the dynamics of the client’s problems and strengths. The client data from above should be related as fully as possible to the theoretical approach that you have chosen. Incorporate your analysis into your impressions in the sections below.
Describe how the individual defines his/her disability from one of the theoretical perspectives discussed in class to help analyze the data in your psychosocial assessment.
Select one of the models presented in the course (e.g., medical model, biopsychosocial model, etc)
Describe the model then discuss how your client places him or herself in the model. Critically think of how your client is coping. Comment on that as it relates to the material presented in your readings and lectures. You may also consult other sources; you do not need to cite the source within the assessment, but append a reference list of sources in APA style.
Clinical Summary, Impressions, and Assessment
Goals and Recommendations for Work with Client (e.g, treatment plan). In this treatment plan section of your assessment:
identify challenges and problems to be addressed and
present goals and interventions (helping efforts) that are consistent with the theoretical approach that you have chosen above.
Formulate four goals with their associated tasks for client and worker (the goals can be short-term, long-term or both). The goals should be consistent with the theoretical approach that you have chosen above.
Don’t forget to involve your client in your goal setting.
