Biopsychosocial Spiritual Assessment

Employment History

Example: Ms. Banjos describes herself as a "hard worker," and shares how she has worked extremely long hours in low paying factories for past eight years, never earning a promotion or raise. Her income averages between $6,000 and $10,00 per year. Prior to factory work Ms. Banjos was a stay-at-home mom taking care of her five children relying on $200 per month in government assistance, 150 per month in food stamps, and 450.00 per month in child support that she received from ex-husband Jorge, who used to his own roofing company before his terminal cancer diagnosis.

Family Composition

Example: "Carina De Los Dantos Banjos, a 29-year-old single woman from Cozumel, Mexico, has been living in Birmingham, Alabama for the last Ten years. Carina is the mother of five teenage children. Asa, age 12, Lyn, age 13, Chaya age 14, and Syna age 15 live at home, Mesos, age 17, is currently in a boot camp in Stone Mountain, Ga. She states she and the children get along well and that they are all doing very well in school. She sees Mesos every other weekend and is hopeful that the boot camp experience will help him in the long run." Carina states that her children are her reason for living. She has no other family members in the United States. Her ex-husband Jorge lives with his current wife and 2 other children approximately 1.5 hours away in Augusta, Ga. He has not seen the children in approximately eighteen months due to a terminal illness. Prior to his illness he would take the kids out to dinner and shopping at least twice per month.

Religious and Spiritual Involvement

Example: Carina describes herself as a 'serious Catholic.' She attends Sunday Mass weekly, along with her four children. She also attends other weekly, social gatherings organized by her church. She states that the church has been an excellent source of support for her and the children. They have provided, food, transportation, and financial support during times of need.

Health

Example: "Carina is in general good health, although she has not visited a doctor in several years and complains sometimes about headaches and general tiredness. she has consulted with her friend Sasha who is a nurse in regard to the symptoms. Sasha seems to believe it is stress related. Carina is currently managing this condition through non-prescription medication, such as aspirin.

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BIOPSYCHOSOCIAL SPIRITUAL

Biopsychosocial Spiritual Assessment

Name

School of Behavioral Sciences, Liberty University

Author Note

I have no known conflict of interest to disclose.

Correspondence concerning this article should be addressed to

Email:

Biopsychosocial Spiritual Assessment

Type a brief introduction to the family.

Identifying Information:

Identify demographic information for members of the Rodriquez family

Demographic Information:

Age, sex, ethnic group, current employment, marital status, physical environment/housing: nature of living circumstances (apartment, group home or other shared living arrangements, homeless); neighborhood.

Referral Information:

Referral source (self or other), the reason for referral. Other professionals or indigenous helpers currently involved.

Data Sources Used in Writing this Assessment:

Interviews with others involved (list dates and persons), tests performed, other data used.

Presenting Problem:

Description of the problem, and situation for which help is sought as presented by the client. Use the client’s words. What precipitated the current difficulty? What feelings and thoughts have been aroused? How has the client coped so far?

Who else is involved in the problem? How are they involved? How do they view the problem? How have they reacted? How have they contributed to the problem or solution?

Past experiences related to current difficulty. Has something like this ever happened before? If so, how was it handled then? What were the consequences?

Background History:

Developmental history: from early life to present (if obtainable)

Family background: description of the family of origin and current family. The extent of support. Family perspective on client and client’s perspective on family. Family communication patterns. Family’s influence on the client and intergenerational factors.

Intimate relationship history, known current or past relationships

Educational and/or vocational training

Employment history

Military history (if applicable)

Use and abuse of alcohol or drugs, self, and family

Medical History:

Birth information, illnesses, accidents, surgery, allergies, disabilities, health problems in family, nutrition, exercise, sleep

Mental Health History:

Previous mental health problems and treatment, hospitalizations, outcome of treatment, family mental health issues.

Nodal Events:

Deaths of significant others, serious losses or traumas, significant life achievements

Cultural Background:

Race/ethnicity, primary language/other languages spoken, the significance of cultural identity, cultural strengths, experiences of discrimination or oppression, migration experience, and impact of migration on individual and family life cycle.

Religion:

Denomination, church membership, the extent of involvement, spiritual perspective, special observances

Assessment:

What is the key issue or problem from the client’s perspective? From the worker’s perspective?

How effectively is the client functioning?

What factors, including thoughts, behaviors, personality issues, environmental circumstances, stressors, vulnerabilities, and needs seem to be contributing to the problem(s)? Please use systems theory with the ecological perspective as a framework when identifying these factors.

Identify the strengths, sources of meaning, coping ability, and resources that can be mobilized to help the client.

Assess client’s motivation and potential to benefit from intervention

Recommendations/Proposed Intervention:

Tentative Goals (with measurable objectives and tasks)

One Short-term

One Long-term

Possible obstacles 

Genogram

Complete a Genogram of the family.

Rodriquez Case Study

Juan and Alena Rodriquez Mother: Maria, age 25, Hispanic (undocumented) Father: Mateo, age 30, Hispanic (uninvolved) Children: Juan age 5 Alena, age 4

Presenting Situation: Mr. Garcia, Ms. Rodriquez’s landlord, went to Ms. Rodriquez home Saturday afternoon at 2:00 p.m. to make some repairs and discovered that the children were left home alone. When Mr. Garcia entered the home, he observed Juan giving Alena a glass of Robitussin because she had a "head hurt." Juan stated that his mother told him to give Alena some Robitussin today, because she had not been feeling well the night before.

While at the home, Mr. Garcia also noticed that there were dirty dishes in every room, clothes strewn throughout the house, roaches in cupboards, and mice in the pantry. Mr. Garcia also noticed that there was an opened box of cereal, from which the children were having lunch, according to Juan.

There was no phone in the house, but Ms. Rodriquez had left her work number posted on the fridge and had instructed Juan to go next door to their elderly neighbor, who is wheelchair bound, and call if there were any problems. Mr. Garcia called the number from his cell phone and left a message for Ms. Rodriquez, saying that she needed to return his phone call immediately. Mr. Garcia then called the police department, who immediately responded and contacted the Department of Social Services

When the on-call worker arrives at 3:00 p.m., he observes that the description given above of the home is accurate, as evidenced by dirty dishes, strewn clothing, roaches, and mice. While being interviewed by the worker, with Mr. Garcia translating- Juan stated that his mother made breakfast for them before she went to work. Juan stated that she has instructed them to eat cereal throughout the day when they are hungry, as she does not allow them to cook or use the microwave. Shortly after the worker's arrival, Ms. Rodriquez contacted Mr. Garcia, who brings her "up to speed" on the situation. Ms. Rodriquez spoke to the on-call worker and said that she would explain the situation to her employer and ask for him to let her off at 4:00 p.m., instead of 8:00 p.m.

At 4:00 p.m. Ms. Rodriquez called the worker and stated that she was on her way home. The worker agreed to wait for her arrival. When Ms. Rodriquez arrived, the worker observed that Ms. Rodriquez was driving her own vehicle. The worker also noticed that Ms. Rodriquez responded to and interacted with the children appropriately and observed that they seemed to have a close bond with her. The worker noticed Ms. Rodriquez spoke English very well but spoke Spanish to the children.

During the initial interview, Ms. Rodriquez appeared to understand the need for Family Services to be involved and agreed to cooperate in any possible way. Ms. Rodriquez works in a factory, where she earns $4.85/hr. Ms. Rodriquez illegally crossed the U.S./Mexican border and has no legal U.S. identification. Last month she was required to work seven-hour days, six days each week. As of last month, her employer is now requiring her to work twelve-hour days, five days each week.

Ms. Rodriquez is afraid to object because she is afraid that her employer will either report her to Immigration Enforcement or fire her. Her childcare provider could care for her children when she was working seven-hour days, but not when she is working twelve-hour days.

Ms. Rodriquez stated that she has to work so she can pay her bills and provide food for her family. Ms. Rodriquez admitted that she has been leaving her children at home alone, since her employer required her to increase her hours. She stated that on her off days she tries to clean the home and attend to her children as much as possible but stated that it is difficult because she is often so tired. The on-call worker stated that there were some immediate safety issues in the home, such as the cleanliness of the home and the fact that Ms. Rodriquez has been leaving her young children alone for extended periods of time for the past month. Given their ages and the fact that Juan was giving Alena a glass of Robitussin, instead of the proper dosage, it is clear that these children are not able to adequately care for themselves.

Mr. Garcia, who has known Ms. Rodriquez since she came to the U.S. six years ago, agreed that he and his wife would care for the children. Ms. Rodriquez, Mr. Garcia, and the on-call worker agreed to this plan and signed a Safety Plan. Ms. Rodriquez undocumented status was not mentioned to the police department.

Current Situation: A worker interviews Juan, Alena, and Ms. Rodriquez the next day in their one bedroom, one bath mobile home located in a poverty stricken neighborhood near downtown San Antonio, Texas.

Background Summary: Ms. Rodriquez stated that she was raised in an upper-class Mexican neighborhood with a large sibling group. She grew up Roman Catholic and attended services weekly with her family. Religion played an important role in the family life.

She stated that she met Mateo Rodriquez, the father of her children, when she was seventeen and fell in love with him. Ms. Rodriquez stated that her parents strongly cautioned her against dating Mr. Rodriquez because his family status was "below" their own. Ms. Rodriquez stated that she defied her parents and moved into Mateo’s one-bedroom shack - an act for which her parents later disowned her.

After one year of living together, Ms. Rodriquez stated that she agreed to come to the U.S. with Mr. Rodriquez. Ms. Rodriquez stated that she left without her family's knowledge as they had disowned her. She was determined to show her parents that she could make it without their help. Ms. Rodriquez illegally came into the U.S. with her boyfriend, Mateo Rodriquez, six years ago. They lived with Mr. Rodriquez relatives until Mateo got a job and moved them into their own place six months later.

Ms. Rodriquez stated that shortly after their move, she became pregnant with Juan. She experienced issues during her pregnancy due to a history of hypertension and heart disease. Ms. Rodriquez stated that after Juan was born, she began to suspect that Mr. Rodriquez was in an intimate relationship with another woman when he began staying out later than usual and withdrawing from her and their child. There were also episodes of verbal abuse and fights that led to Ms. Rodriquez being pushed and shoved by her husband. Ms. Rodriquez stated that she confronted Mr. Rodriquez with her suspicions of infidelity, and he admitted to having an affair with his American co-worker.

Ms. Rodriquez stated that Mr. Rodriquez apologized for his cheating and abusive behavior and promised to devote himself to his family. Ms. Rodriquez stated that their relationship was wonderful until Mr. Rodriquez abruptly left her for the woman with whom he was previously having the affair. Ms. Rodriquez stated that it was shortly after Mr. Rodriquez left her, that she discovered that she was pregnant with Alena and her issues with hypertension and heart disease increased. Ms. Rodriquez stated that Mr. Rodriquez was initially involved in both of his children's lives and supported them financially until he married the American co-worker and moved to Dallas, TX. Ms. Rodriquez stated that after Mr. Rodriquez abandoned them, she was forced to work outside of the home - something that was frowned upon in her family.

Ms. Rodriquez stated that she was able to secure childcare through a former neighbor, who does not work. Ms. Rodriquez stated that she cannot afford formal daycare, as she was only paying this person $25 each week. Ms. Rodriquez stated, "About 6 months ago, the babysitter asked me to pay her more because the children were eating more food. I told her that I could not pay her more money, and she got really angry." Ms. Rodriquez further stated that the babysitter threatened to stop caring for her children on two occasions.

Ms. Rodriquez said, "both times I was able to get her to keep watching them." Ms. Rodriquez stated that when she approached the babysitter, informed her of her extended work hours, and asked her to care for the children during that time, she "blew up" and said she would not work for such low wages. Ms. Rodriquez stated that the babysitter has refused to help her with her children since that time.

Ms. Rodriquez stated that she has been forced to leave her children alone at home so that she could provide for them. Ms. Rodriquez states that she feels terrible that she has to leave her children at home alone and goes over rules with them every morning before she leaves for work. Ms. Rodriquez stated that she has not applied for any Government benefits (Food Stamps, Daycare Assistance, and TANF) because she did not want to be reported to Immigration Enforcement. Ms. Rodriquez stated that her home started becoming cluttered after she began working twelve-hour shifts. Ms. Rodriquez stated that she wants to keep her home in better condition, but just cannot seem to find the time or the energy to do so.

Safety Issues • Ms. Rodriquez leaves Juan and Alena home alone due to a lack of childcare. • The house is unsanitary and may be a health hazard. • Inadequate financial resources and No social network of support.

Strengths • Ms. Rodriquez is employed. • Ms. Rodriquez has transportation. • Ms. Rodriquez cooks breakfast for her children before she leaves in the morning. • Ms. Rodriquez loves her children. • Ms. Rodriquez has informed Juan how to call for help in case of an emergency. • Ms. Rodriquez does not allow Juan and Alena to cook or use the microwave in her absence. • Ms. Rodriquez goes over the ground rules with her children every morning before she leaves for work. Juan and Alena have a strong bond with their mother. • Ms. Rodriquez is willing to collaborate with this agency regarding her children's safety. • Ms. Rodriquez realizes that leaving her children alone is dangerous.

Needs • Ms. Rodriquez needs to have adequate daycare arrangements for her children. • Ms. Rodriquez needs to find employment that pays increased wages. • Ms. Rodriquez needs financial stability. • Ms. Rodriquez needs to expand her support group and her social network. • Ms. Rodriquez needs to locate the father of her children and pursue child support.

Available Resources Ms. Rodriquez and her children live in a medium-sized city with a population of 200,000 people, with a growing Hispanic population. Ms. Rodriquez is now aware that she can receive some government-sponsored and other services without having to provide proof of her citizenship. The Department of Social Services Resources staff in this county are capable and willing to assist Rodriquez in connecting to and obtaining these services. There are also churches and other non-profit organizations that may be able to aid and social support to her family.