Final Paper – Risk Assessment, Safety Plan and Case Management Plan with Resources

Appendix A An Outline for a Biopsychosocial Assessment and Intervention Plan

I. Referral How and why did the client(s) get to the agency? Is the client self-referred? Is the client voluntary or involuntary?

II. Description of Client Who is the client? Briefly document relevant identifying information including: Age, gender identity, marital/partner status, race, ethnicity, sexual orientation, religion, social class, income source(s), disabilities, level of education, prominent health issues, medications, substance use, and legal issues.

III. Presenting Issues and Concerns What are the client’s complaints? What are the larger presenting issues? How does the client view these concerns/issues? How do other people (family, friends, agency, work, school, courts, physicians, religious community, you, etc.) view the concerns/issues?

When did these concerns/issues begin? Is there an identifiable precipitant? Why is the client coming in now?

How has the client dealt with these or similar concern/issues in the past? What would the client most want help with?

IV. Assessment of Relevant Contextual, Historical, and Intrapersonal Factors

a. Current context What are the family, social community, work, and other issues relevant to an understanding of the client and the problem? (An eco- map and/or a family genogram, identifying family, and environmental resources may help clarify these intertwining issues.)

• Are the client’s basic needs met? (Housing, food, clothing, utilities, emergency, or situational needs such as diaper services or money for medicine or care of pets while inpatient?) What are the clients’ strengths in meeting basic needs? Are these needs met in a culturally appropriate/ sensitive manner?

J. W. Drisko and M. D. Grady, Evidence-Based Practice in Clinical Social Work, Essential Clinical Social Work Series, DOI: 10.1007/978-1-4614-3470-2, � Springer Science+Business Media New York 2012

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• What are the clients’ income sources? Are they stable? Can they be improved? What are the clients’ strengths in meeting basic needs? Is this income obtained in a culturally appropriate/sensitive manner?

• Are there language issues for the client in the services and communities to which they relate? In meeting basic needs? In the school or workplace? Are interpreters available? Is language training accessible if sought? What strengths and challenges does language pose for the clients?

• If the client has disability issues, how adapted/accessible are home, neighborhood, workplace, schools, stores, and professionals? How are communication needs met? How are transportation needs met? Does the client have access to needed equipment for safety and for daily living skills? Does the client have training to use such equipment/devices? How is this disability understood in the clients’ cultural context? What strengths are evident related to this disability?

• Are the client’s medical and dental needs met? (This includes routine checkups, assessment of illnesses, emergency care, immunizations, dental care, rehabilitation services, access to medications or rehabili- tation equipment, access to nursing help, and access to long-term care, etc,) Are the services culturally appropriate? Accessible?

• Are the client’s safety needs met? (Domestic violence, abuse or neglect of children or elders, violence in housing, neighborhood, and specific threats?) Is the client’s physical environment safe? (Free of fire hazards, with accessible fire escapes, no lead paint, etc.?)

• Does the client pose a hazard to the safety of self or others; specifically is there suicide risk or lethality risk? Fire setting risk? (If any of these apply, a specific detailed evaluation and documentation is also required.)

• Is domestic, partner, or marital violence an issue? If so, is a safety plan in place?

• Are there child protective, disability, or elder protective issues for the clients? If so, is there a service plan? What services are involved? What services/needs are ignored?

• Are there legal issues for the clients? Any court involvement, restraints, obligations? Are there obligatory services, costs, or settlements unpaid?

• What is the client’s immigration status? Could this be a source of being unsafe or exploited?

• What is the client’s religion or spiritual beliefs? What level of involvement do they have with their religion or spiritual organization, its practices, and its community? Does the client have other connections to spirituality? How do these (religion and/or spirituality) shape the meaning of the client’s life?

• What are the client’s recreational interests? How and where are these met? Are there barriers to recreational activities?

• What are the client’s key social supports? Are they accessible?

260 Appendix A: An Outline for a Biopsychosocial Assessment and Intervention Plan

• Are there important social policy or social structural aspects to the client’s situation and problem? Has (or could) the client joined with others to address these issues? How?

b. Historical influences Summarize, as relevant, past material about

• Client’s childhood, including developmental history. • Relationships with family of origin. • School and work history. • Previous experiences with social, medical or psychological services. • Intimate relationships.

c. Coping strengths and weaknesses

• What are the client’s key self-reported strengths? Are there other strengths you observe or can infer?

• How does the client process information? Protect themselves from anxiety and stress? Who do they turn to for support and nurturance?

• How does the client characteristically interact with others? Are these strategies successful in meeting the client’s needs? Are they routinely problematic? Can the client show flexibility in style of interaction?

• How do these strengths, challenges, and abilities fit with the client’s social and institutional resources? What resources or obstacles facilitate or inhibit the client’s mastering current issues/concerns?

• What role do current life cycle tasks play in relation to the concerns and issues that have been identified?

V. Formulation Develop a brief, clear, biopsychosocial summary of the above material that integrates relevant developmental, theoretical (i.e., psychodynamic, cognitive- behavioral, P–I–E, family systems, or risk and resiliency), family, and sociocultural issues. How would you state the client’s dilemma in easily understood words that capture the key concerns and strengths?

VI. Plan for Intervention Drawing upon the formulation, describe your plan for intervention. Identify your goals, separating immediate from long term. What would be the core elements of a treatment contract with this client? Are there elements that might be uncomfortable or unacceptable to the client?

VII. The Best Research Evidence Given the proposed plan for intervention, what does the research evidence indicate are the best likely effective treatments or services to discuss with the client? Are the treatments realistically available and can they be funded? Are these treatments likely to be accepted by the client?

VIII. Values and Ethics: The Worker’s own Values and Experience What are the value, ethical, diversity, personal reactions, and other challenging issues that surface in this case? Will these alter what you can offer and provide?

Appendix A: An Outline for a Biopsychosocial Assessment and Intervention Plan 261

IX. Organizational Issues How will your agency mission and practices shape further service delivery? What organizational factors aid successful services for this case? What factors are barriers or impede services for this case?

X. Social Change Goals What social change goals can be part of, or related to, your work with the client? What resources might you mention to the client as ways to promote the changes they wish to help make? What resources might you help connect the client with to promote these changes? How might you work to promote social changes related to this client and case?

� 1997, 2005 by James Drisko and Carolyn DuBois—used with permission from the authors

262 Appendix A: An Outline for a Biopsychosocial Assessment and Intervention Plan