Assignment

Bio-psycho Case Assessment Format

“The Rosa Lee Story”

A three (3) generational, at minimum, genogram must be included with the Assessment

PART 1

Identifying Information

Give name, age, race, sex, address, marital status, general physical appearance, including stature/size, and marital status

Referral Information

How did this client come to you or your agency? Is the client self-referred? List referring information, if applicable.

Reason for Referral/ Presenting Problem

This is the section where you briefly summarize why the client is seeking services.

Family Relationship Status

List the members of the immediate family and briefly discuss the status of their relationships. Names and ages of immediate family members should be included.

Current Family Social Status

Information regarding housing and financial status should be included in this section.

Background

This may be the longest section of the Case Assessment because it contains all pertinent information about the client, family, and environment of the client. It is the bio-psycho-social-spiritual background of the client.

Use the following headings to organize the information in this section. Enter the pertinent information under the headings in order to be thorough, present quantities of material in an organized manner, to make it easier for you to write, and to make it easier for others to read.

Family History

Discuss the family of origin in this section. Include relevant information about extended family members. A relevant fact would be, “the father had a significant relationship with his paternal uncle.” Major family life events should be discussed in this section. Previous marriages and divorces should be included.

Social History and Connections

Information regarding the client and family community support should be included in this section. Formal and information social groups and organizations that are relevant to the family should be discussed in this section.

Spiritual / Cultural History and Connections

Discuss the client’s past and present spiritual and/or cultural connections.

Education History

Give highest level of education obtained and any significant educational milestones or issues.

Employment/Vocational History (includes Military History)

Give brief employment history with more specific information given about current status.

Physical / Medical History This section should include both a physical developmental history and current health status. Also, include medications, especially medications currently being taken.

Psychiatric and/or Psychological History This section should include any previous or current involvement with psychiatrists, psychologists, or mental health professionals. For example, “Psychologist, Barbara Nicol, PhD, administered the assessment or test or evaluation Mr. Jones on 2/12/04. Any known recommendations of assessment should be included.

Previous Services received for related issues Services for physical, social, spiritual, psychological/psychiatric concerns, particularly previous services for the presenting issues should be included in this section.

PART 2

Strengths and Needs of Client

Discuss the strengths and the needs of the clients. This can be written in narrative style or can be written as lists.

Professional Impressions and Assessment: This section involves your critical thinking and assessment skills. There should be NO new information here. In this section, take the information gathered and and give your assessment of: the client and the client’s situation. This section should contain what you think are strengths (resources of the client and the client’s environment that can be called upon in addressing the problem, or the client reaching goals, etc.), areas of concern or areas for growth, and your assessment of the general situation or need and problems to be addressed. In the medical profession this section would include a “prognosis.” In social work we state strengths and areas of concern and, in doing so; we are stating how probable reaching certain goals will be. In this section, sum up in the Case Assessment and give a professional assessment, current stage of development and rationale for the selected stage of development.

Case Plan / Goals: In this section the worker sets out a plan for addressing the concern or reaching goals. The plan should not be stated in a narrative, but concisely and precisely, preferably in a list: who, what, when----who will do what and by what date in order to most likely meet the needs of the client. Referrals should also be included in this section.

What are the goals and what steps will be taken to reach those goals? They can be separated into categories of

Short-term Goals : things that can be achieved in a matter of days or weeks, and

Long-term Goals : things that will likely take months or years.

Signatures and Dates

______________________________________

(Signature is normally required, when submitted electronically for this assignment you can type your name)

Your name typed, your title typed

___________________________________

Date

Dated at the time of your signature

Has Assessment been reviewed with client? ___yes ____no

___________________________________

Client Signature (For the purpose of the assignment we will assume you developed your plan and goals with your client. Please also type the client name here in order to correctly complete the assignment.)

__________________________________

Date