Assignment

Running head: ASSESSMENT REPORT 1

ASSESSMENT REPORT 6

Assessment Report

Christy Killian

Walden University

11/15/2020

Assessment Report

History of Client

The client articulates that he has used both alcohol and drugs in the past six months. The substance and alcohol use has prompted him to use more of the drugs as compared to the last amounts used. Further, he is unable to cut on the use of alcohol and drugs. Even after going to support and self-help groups, he has been unable to reduce the addiction or even quit the drugs completely. Symptoms experienced mostly are blackouts and memory loss after using alcohol and drugs, feeling sick, depression, and shaking when he stops taking the drugs. The drinking and substance abuse problem is also associated with increased problems in the family and social level. Friends, as well as family, are stipulated to always evade him when he is high.

Also, addiction has influenced his work and school work negatively. This can be associated with decreased attention and performance rates during assignments. However, he has not been in any legal problems due to drug use. Most times, the client feels guilty for his drinking and substance abuse behavior. This has a consideration of the lack of drug and alcohol problems before. Various family members have both drinking and drug problems. The client, however, admits that he doesn’t consider himself to have substance abuse and drinking problem. The client assessment shows that the client suffers from alcohol and substance use addiction.

Referral

The referral segment considers psychological evaluation as well as speech and language evaluation. The process enables the identification and gathering of personal information leading to the testing of the client’s condition. The referrals associated with the patient, such as family and close friends can be imperative in filling gaps the patient left blank. This would provide additional information on the scope of the patient’s condition. Information attained directs on behavioral and social changes that need to be addressed in the intervention programs. In addition, information obtained from referrals is used to determine the appropriate intervention and placement programs effective for the patient. In this case, a referral could be attained from a support group leader or member as well as a workmate.

Referral sections can also be utilized to stipulate the reason for the problem commencement and persistence. This is because the individuals chosen as referrals can have more detailed information that the client did not include in the self-assessment report. A request for the information as well as medically-related issues can facilitate an understanding of the changes and reasons for concern. Causative and contributing factors to the problem can be facilitated by both evaluation and referral information. However, information to be asked in the referral section have to clarify the purpose of the evaluation and should not necessarily be questions but can also involve summaries. Therefore, information obtained from the family and friends will consider how they perceive the client’s problem commencement and persistence.

Background Information

Sources to be considered in background information will entail regular contacts of the client such as work supervisor, parent, teacher, and siblings. Background information obtained has to be pertinent with the referral information obtained, expounding the problem reflecting in problem evaluation. Permission is an important aspect of obtaining background information to enable both consent and confidentiality. In this case, the individual is an adult; therefore, he is able to give consent. However, for confidential purposes, permission will be obtained to carry out a background check and collect information on medical records. Anonymity will be undertaken to ensure confidentiality as an ethical obligation. This is in consideration of the client’s behavior and how it is related to the condition affecting the regular individuals he associates with.

Structured interviews will be used during face-to-face communication and telephone calls to contacts. All the sections will regard client history from birth to present to the parent, work history from employment to the supervisor, attendance to the group from the support group leader, and attendance and school performance history from the teacher. Structuring the interviews in such sections simplify and amplify on relevant information to be obtained in a logical progression. Recent information will be compared with past information to help in understanding the causative factors of the addiction. In addition, integration of the information from different sources will expound the evaluation. Avoidance of sensitive content from the sources will be enabled through the change of questions and asking open-ended questions.

Description of Data Findings

The summary of the patient’s condition will be represented systematically after the analysis and interpretation of the data collected. For instance, organizing and analyzing information from the client, referrals, and background information will comprehensively result in the identification of the specific problem and its causative factors. This would lead to treatment interventions which are not only aimed at enabling the client to recover, but also enabling the patient to develop coping skills avoiding relapses. Consistencies of data collected would reduce variances in the evaluation processes articulating clarity in the overall assessment report. Further, organizing the information would identify data inconsistencies that need to be clarified prior to the client’s treatment.

Support of patient details through current assessment is vital in the description of data findings. This would provide explanations of client themes and patterns observed in the condition. Strong evidence provision articulates data was carefully analyzed and contrasts accommodated for accurate outcomes. Further, data support in the description can be vital in explaining contradictions and inconsistency in data. For example, different sources applied to obtaining background and referral data can have differing information. This considers differential periods that each source has known the client and own perceptions on the client’s behavior. The information can be difficult to integrate hence requiring logical explanations on the data inconsistencies. Reports articulating the descriptions of data findings of the client are to be logically organized for effective interpretations.

References

Litchenberger, E., Mtaher, N., Kaufman, N. & Kaufman, A. (2004). Essentials of assessment; report writing. John Wiley & Sons, Inc.

Perkison, R. (2017). Chemical dependency counseling; a practical guide. 5th edition. SAGE publications.