S1

CASE ASSESSMENT

DEMOGRAPHIC INFORMATION

i. Client’s name

ii. Age

iii. Gender

iv. Relationship status

v. Ethnicity

vi. Level of Education

vii. Occupation

viii. Length of employment

ix. Age and gender of any children

x. Any problems with basic needs

CHIEF COMPLAINT/PRESENTING PROBLEM

In the this section of your psychosocial assessment you should:

● Describe the problem for which the client came (or was referred) for help.

○ Include client’s definition of problem/need and expectations of service.

○ Include a brief history of the presenting problem:

■ Length of duration of the problem

■ Prior attempts to resolve the problem

■ Previous involvement with social agencies for assistance with the problem

○ If client is in crisis or considered “high risk” (e.g., in danger: of being abused, using violence against someone else, suicidal, decompensating, relapsing to drug use), describe and offer brief assessment of the risk

CHIEF COMPLAINT/PRESENTING PROBLEM EXAMPLE “Hal Solomon is a 32-year old entrepreneur whose presenting problem is a sense of unworthiness over earning more than a million dollars each years in the past 10 years of his work career. He says that the amount of money is considerably out of keeping with the degree of energy used, and that compared to people who “real work,” it seems completely wrong for him to earn so much money.

Mr. Solomon came to the interview on time, wore dress slacks and a polo shirt, is deeply tanned, and says that he is 6’1’’ and weighs 165 pounds. He runs 5 miles a day and works out at the gym at least an hour every day. He wore no rings or other jewelry, but he did have on a gold Rolex watch. Initially, he moved around a great deal in his chair and his fingers continually tapped on the arm of his chair. After 5 minutes, he slumped back in his chair, and, from time to time, wiped tears from his eyes as he discussed the impact his career has had on his former marriage, family life, and on issues of intimacy. He comes to treatment for help in resolving problems of continued feelings of unworthiness, depression, and guilt that have lasted a duration of more than 2 years and which began with his divorce several years ago.”

From Glicken, M.D. (2005) Improving the effectiveness of the helping professions: An evidence based approach to practice. Thousand Oaks, CA: Sage.

DESCRIBING THE CLIENT

Your general description of the client should include the following items:

•Client’s appearance, attitude, affect, and interpersonal style during the interview/s

•Mention any apparent problems with memory, thinking, speech, or client’s sense of reality

•Note any signs or mention of anxiety, depression, or other mood states, if they are present

•Indicate how the client related to you during the interview/s

DESCRIBING THE CLIENT EXAMPLE

“Throughout our interviews, Mr. Solomon continuously expressed concern about his job and his professionalism. Despite these concerns, he always arrived on time for the interviews, which were scheduled after his regular work hours. Thus, he arrived wearing suit and tie to all of these interviews. A few times during our conversations, he would pause; he commented several times that he was having difficulty expressing his feelings and anxiety to a relative stranger. Despite these concerns, however, after a few meetings, he seemed much more at ease, even engaging me in casual topics of conversation, even though at the beginning of his sessions he refused to talk about anything other than his anxiety.”

FAMILY COMPOSITION AND BACKGROUND

The family composition and background section should mention:

● Nuclear family members and significant relationships; list members, ages, marriage dates, deaths, divorces. Describe relationships-focus on marital and parental strengths and difficulties, if relevant.

● Family of origin (family with whom one grew up); list members, ages, where they live, deaths, divorces. Describe all of these relationships.

● History of relevant substance abuse, legal problems, and/or psychiatric problems among family members.

FAMILY COMPOSITION AND BACKGROUND EXAMPLE Hal has been divorced from his former wife Jane, also 32, for four years. They met in college and married right after graduation in June 2010. Their only child, Emma, was born in September of the same year. Hal pursued his business interests while Jane raised Emma. There was never a feeling of family for any of them and Hal and Jane grew apart and they divorced. Hal sees Emma occasionally. Jane is dating a man and Hal believes that they will marry soon.

Hal was born in the Midwest. His mother, Grace, died of breast cancer last year at age 54. His father, Otto, has worked in an automobile plant for 40 years, often working seven shifts a week to support the family. Hal has two younger sisters, but they moved away after high school and he has not been in touch with them since then, except for his mother’s funeral.

CLIENT’S GOALS

This is where you state what the client wants to get from therapy.

PSYCHOLOGICAL FUNCTIONING/SYMPTOMOLOGY

The psychological and psychiatric functioning and background section should mention:

● what has been the client’s reaction to the problem which brings them to therapy

Length of psychosocial symptoms

Any similar symptoms in the past

Any attempts to decrease symptoms and the results.

History of mental health/psychiatric problems, prescription medication, addictions (e.g., alcohol and other drug use).

● History of physical, mental, and/or sexual abuse or neglect

PSYCHOLOGICAL FUNCTIONING EXAMPLE

“[Mr. Solomon] reports... depression or anxiety in his life, which occurred about the time he decided to marry. He believes the cause of his depression was the conflict with his parents over the marriage. He says that he is healthy, although he sometimes feels easily fatigued.... He was on a tranquilizer several years ago because of anxiety and depression during the divorce but cannot remember the name of the medication. He says that it made him sleepy and that he discontinued its use because it interfered with his work.”

CRISIS/SAFETY

Is this client experiencing any current crises or problems with safety?

 Describe type and severity

 Describe your plan to address this

MEDICAL HISTORY

The physical functioning, health conditions and medical background section should mention:

Physical development, general health, disabilities, and current functioning.

History of disease, accidents, genetic predispositions, and prescription medication

MEDICAL HISTORY EXAMPLE

“Simon Kowalsky is in general good health, although he complains sometimes about headaches and general tiredness. He has consulted with his general physician in regards to this condition, who seems to believe it is stress related. He is currently managing this condition through non-prescription medication, such as aspirin. His family, in particular on his father’s side, has a history of heart disease, which contributes to Mr. Kowalsky’s uneasiness concerning his stress levels .

CLIENT’S STRENGTHS, CAPACITIES, RESOURCES

The client strengths, capacities, and resources section should address:

● How does the client cope? What are his/her strengths and problem-solving capacities? What are his/her limitations to deal with the current problem/s?

● Social functioning, (are there any significant friendships, interpersonal relationships, support network?)

● Use of community organizations or resources (e.g., as client, member, volunteer)?

● Hobbies/leisure involvement.

CLIENT’S STRENGTHS EXAMPLE

“While [Mr. Solomon] complains of depression and fatigue, he continues to do well in his work, exercises daily, and has widely invested his large income for the future. He is an avid reader and has tried to use available literature to understand and resolve many of his problems, sometimes effectively. He states that he has a number of friends and sings in his church choir. Last summer he joined a local baseball team and intends to this summer as well. He likes sports and goes to games with friends.”

CLINICAL SUMMARY, IMPRESSIONS, ASSESSMENT The clinical summary, impressions, and assessment section should:

● First give a brief, 3-5 sentence summary of what you have already written:

○ Identify the primary problem, need, or concern the client is dealing with and contributing factors.

○ Also, describe the sense of urgency the client has with the problem/s.

○ Identify secondary problems, needs, or concerns if these are raised.

● Summarize how the client appeared during the interview/s.

○ Give an overview of client’s mood, signs of anxiety or depression, problems with memory, speech, sense of reality, judgment, attitude toward their situation/difficulty.

○ Indicate how the client related to you. Your impressions give important clues to where the client is right now and how the client is handling the problem emotionally and cognitively.

● Note the client’s expectations of service.

CLINICAL SUMMARY EXAMPLE

“Mr. Solomon is a 32-year old divorced Jewish entrepreneur who seeks help for feelings of guilt and depression over the large amount of money he has made in a career that he describes as “frivolous.” He describes ongoing feelings of isolation and loneliness and is concerned over his inability to trust others. The onset of these feelings seems to have coincided with the death of his parents and the divorce from his wife as a result of her infidelity. All three events took place within months of one another.

Mr. Solomon has many positive behaviors that should be particularly helpful in his treatment. He is successful at work; he is introspective and feels concern over his current emotional state; and he has some insights into the origins of his problems with his parents, siblings, and former wife. He appears to be highly motivated to change. Although eh suffers from a steady degree of depression, he is still able to work at a successful level. He longs for more intimacy and wants to form the types of caring relationships that have been so elusive in his life. He values education and has made a conscious effort to improve his general level of knowledge in an attempt to make up for an early withdrawal from college.”

GOALS AND RECOMMENDATIONS The goals and recommendations for work with client section should:

● Identify goals for work with client.

 Correct order of problems to address first:

1.Issues of safety

2.Any issue that requires reporting

3.Any non-lethal or non-reporting crisis

4.The problem(s) generating the greatest symptoms

● Recommendations for service and resources

○ Modality (what type of treatment).

○ Length of time (how many sessions? Long term, short term?)

● Next steps.

GOALS AND RECOMMENDATIONS EXAMPLE

Problem List:

1. Social Anxiety

2. Low motivation at work

3. Stress

“Given Mr. Kowalsky’s problems with social anxiety, which is causing problems at work, long-term therapy is suggested. Mr. Kowalsky has agreed and has agreed to a minimum of three months, with sessions per week using: CBT for Social Anxiety; Motivational Interviewing for work problems; and Relaxation techniques for stress. After this initial three months, Mr. Kowalksy has agreed to reconvene with me, and consider further options if needed. In the meantime, he has agreed to keep me regularly updated on his stress levels by meeting with me once every two weeks.”

CASE ASSESSMENT

DEMOGRAPHIC INFORMATION

i. Client’s name

ii. Age

iii. Gender

iv. Relationship status

v. Ethnicity

vi. Level of Education

vii. Occupation

viii. Length of employment

ix. Age and gender of any children

x. Any problems with basic needs

CHIEF COMPLAINT/PRESENTING PROBLEM

In the this section of your psychosocial assessment you should:

● Describe the problem for which the client came (or was referred) for help.

○ Include client’s definition of problem/need and expectations of service.

○ Include a brief history of the presenting problem:

■ Length of duration of the problem

■ Prior attempts to resolve the problem

■ Previous involvement with social agencies for assistance with the problem

○ If client is in crisis or considered “high risk” (e.g., in danger: of being abused, using violence against someone else, suicidal, decompensating, relapsing to drug use), describe and offer brief assessment of the risk

CHIEF COMPLAINT/PRESENTING PROBLEM EXAMPLE “Hal Solomon is a 32-year old entrepreneur whose presenting problem is a sense of unworthiness over earning more than a million dollars each years in the past 10 years of his work career. He says that the amount of money is considerably out of keeping with the degree of energy used, and that compared to people who “real work,” it seems completely wrong for him to earn so much money.

Mr. Solomon came to the interview on time, wore dress slacks and a polo shirt, is deeply tanned, and says that he is 6’1’’ and weighs 165 pounds. He runs 5 miles a day and works out at the gym at least an hour every day. He wore no rings or other jewelry, but he did have on a gold Rolex watch. Initially, he moved around a great deal in his chair and his fingers continually tapped on the arm of his chair. After 5 minutes, he slumped back in his chair, and, from time to time, wiped tears from his eyes as he discussed the impact his career has had on his former marriage, family life, and on issues of intimacy. He comes to treatment for help in resolving problems of continued feelings of unworthiness, depression, and guilt that have lasted a duration of more than 2 years and which began with his divorce several years ago.”

From Glicken, M.D. (2005) Improving the effectiveness of the helping professions: An evidence based approach to practice. Thousand Oaks, CA: Sage.

DESCRIBING THE CLIENT

Your general description of the client should include the following items:

•Client’s appearance, attitude, affect, and interpersonal style during the interview/s

•Mention any apparent problems with memory, thinking, speech, or client’s sense of reality

•Note any signs or mention of anxiety, depression, or other mood states, if they are present

•Indicate how the client related to you during the interview/s

DESCRIBING THE CLIENT EXAMPLE

“Throughout our interviews, Mr. Solomon continuously expressed concern about his job and his professionalism. Despite these concerns, he always arrived on time for the interviews, which were scheduled after his regular work hours. Thus, he arrived wearing suit and tie to all of these interviews. A few times during our conversations, he would pause; he commented several times that he was having difficulty expressing his feelings and anxiety to a relative stranger. Despite these concerns, however, after a few meetings, he seemed much more at ease, even engaging me in casual topics of conversation, even though at the beginning of his sessions he refused to talk about anything other than his anxiety.”

FAMILY COMPOSITION AND BACKGROUND

The family composition and background section should mention:

● Nuclear family members and significant relationships; list members, ages, marriage dates, deaths, divorces. Describe relationships-focus on marital and parental strengths and difficulties, if relevant.

● Family of origin (family with whom one grew up); list members, ages, where they live, deaths, divorces. Describe all of these relationships.

● History of relevant substance abuse, legal problems, and/or psychiatric problems among family members.

FAMILY COMPOSITION AND BACKGROUND EXAMPLE Hal has been divorced from his former wife Jane, also 32, for four years. They met in college and married right after graduation in June 2010. Their only child, Emma, was born in September of the same year. Hal pursued his business interests while Jane raised Emma. There was never a feeling of family for any of them and Hal and Jane grew apart and they divorced. Hal sees Emma occasionally. Jane is dating a man and Hal believes that they will marry soon.

Hal was born in the Midwest. His mother, Grace, died of breast cancer last year at age 54. His father, Otto, has worked in an automobile plant for 40 years, often working seven shifts a week to support the family. Hal has two younger sisters, but they moved away after high school and he has not been in touch with them since then, except for his mother’s funeral.

CLIENT’S GOALS

This is where you state what the client wants to get from therapy.

PSYCHOLOGICAL FUNCTIONING/SYMPTOMOLOGY

The psychological and psychiatric functioning and background section should mention:

● what has been the client’s reaction to the problem which brings them to therapy

Length of psychosocial symptoms

Any similar symptoms in the past

Any attempts to decrease symptoms and the results.

History of mental health/psychiatric problems, prescription medication, addictions (e.g., alcohol and other drug use).

● History of physical, mental, and/or sexual abuse or neglect

PSYCHOLOGICAL FUNCTIONING EXAMPLE

“[Mr. Solomon] reports... depression or anxiety in his life, which occurred about the time he decided to marry. He believes the cause of his depression was the conflict with his parents over the marriage. He says that he is healthy, although he sometimes feels easily fatigued.... He was on a tranquilizer several years ago because of anxiety and depression during the divorce but cannot remember the name of the medication. He says that it made him sleepy and that he discontinued its use because it interfered with his work.”

CRISIS/SAFETY

Is this client experiencing any current crises or problems with safety?

 Describe type and severity

 Describe your plan to address this

MEDICAL HISTORY

The physical functioning, health conditions and medical background section should mention:

Physical development, general health, disabilities, and current functioning.

History of disease, accidents, genetic predispositions, and prescription medication

MEDICAL HISTORY EXAMPLE

“Simon Kowalsky is in general good health, although he complains sometimes about headaches and general tiredness. He has consulted with his general physician in regards to this condition, who seems to believe it is stress related. He is currently managing this condition through non-prescription medication, such as aspirin. His family, in particular on his father’s side, has a history of heart disease, which contributes to Mr. Kowalsky’s uneasiness concerning his stress levels .

CLIENT’S STRENGTHS, CAPACITIES, RESOURCES

The client strengths, capacities, and resources section should address:

● How does the client cope? What are his/her strengths and problem-solving capacities? What are his/her limitations to deal with the current problem/s?

● Social functioning, (are there any significant friendships, interpersonal relationships, support network?)

● Use of community organizations or resources (e.g., as client, member, volunteer)?

● Hobbies/leisure involvement.

CLIENT’S STRENGTHS EXAMPLE

“While [Mr. Solomon] complains of depression and fatigue, he continues to do well in his work, exercises daily, and has widely invested his large income for the future. He is an avid reader and has tried to use available literature to understand and resolve many of his problems, sometimes effectively. He states that he has a number of friends and sings in his church choir. Last summer he joined a local baseball team and intends to this summer as well. He likes sports and goes to games with friends.”

CLINICAL SUMMARY, IMPRESSIONS, ASSESSMENT The clinical summary, impressions, and assessment section should:

● First give a brief, 3-5 sentence summary of what you have already written:

○ Identify the primary problem, need, or concern the client is dealing with and contributing factors.

○ Also, describe the sense of urgency the client has with the problem/s.

○ Identify secondary problems, needs, or concerns if these are raised.

● Summarize how the client appeared during the interview/s.

○ Give an overview of client’s mood, signs of anxiety or depression, problems with memory, speech, sense of reality, judgment, attitude toward their situation/difficulty.

○ Indicate how the client related to you. Your impressions give important clues to where the client is right now and how the client is handling the problem emotionally and cognitively.

● Note the client’s expectations of service.

CLINICAL SUMMARY EXAMPLE

“Mr. Solomon is a 32-year old divorced Jewish entrepreneur who seeks help for feelings of guilt and depression over the large amount of money he has made in a career that he describes as “frivolous.” He describes ongoing feelings of isolation and loneliness and is concerned over his inability to trust others. The onset of these feelings seems to have coincided with the death of his parents and the divorce from his wife as a result of her infidelity. All three events took place within months of one another.

Mr. Solomon has many positive behaviors that should be particularly helpful in his treatment. He is successful at work; he is introspective and feels concern over his current emotional state; and he has some insights into the origins of his problems with his parents, siblings, and former wife. He appears to be highly motivated to change. Although eh suffers from a steady degree of depression, he is still able to work at a successful level. He longs for more intimacy and wants to form the types of caring relationships that have been so elusive in his life. He values education and has made a conscious effort to improve his general level of knowledge in an attempt to make up for an early withdrawal from college.”

GOALS AND RECOMMENDATIONS The goals and recommendations for work with client section should:

● Identify goals for work with client.

 Correct order of problems to address first:

1.Issues of safety

2.Any issue that requires reporting

3.Any non-lethal or non-reporting crisis

4.The problem(s) generating the greatest symptoms

● Recommendations for service and resources

○ Modality (what type of treatment).

○ Length of time (how many sessions? Long term, short term?)

● Next steps.

GOALS AND RECOMMENDATIONS EXAMPLE

Problem List:

1. Social Anxiety

2. Low motivation at work

3. Stress

“Given Mr. Kowalsky’s problems with social anxiety, which is causing problems at work, long-term therapy is suggested. Mr. Kowalsky has agreed and has agreed to a minimum of three months, with sessions per week using: CBT for Social Anxiety; Motivational Interviewing for work problems; and Relaxation techniques for stress. After this initial three months, Mr. Kowalksy has agreed to reconvene with me, and consider further options if needed. In the meantime, he has agreed to keep me regularly updated on his stress levels by meeting with me once every two weeks.”