In addition to the directions listed on Black Board, here are some guidelines.
All of your writing should be in complete sentences (no bullet points or lists). Use APA format. Use professional language. Do not insert your opinion or thoughts. This is an assessment of an individual’s presenting problem, history, symptoms, functioning, resources, strengths and needs. It should be written well enough to enter into the client’s clinical file, as well as submit to court, other agencies, etc. Imagine multiple professionals will be reading this. Your paper should have citations throughout.
Please note: If you did not gather enough information from the video, fill it in yourself. Your assessment should not say “The video didn’t say anything about his spiritual development.” Instead, you should provide a comprehensive assessment, regardless of how much actual information you have on this case example. I am most interested in that you can complete a full assessment.
Here are a few tips and suggestions throughout the outline. These are not comprehensive, but snippets to give you an idea of how it should be written.
Presenting issue (including referral source)
This section should state the problem/issue that brought the client to the social worker’s attention and who referred the client.
e.g. Joe Smith was referred to ABC Therapy Agency by his substance abuse counselor for treatment related to a history of trauma, grief and loss. Joe’s sister was killed in car accident 2 years ago. Although Joe has been clean of alcohol and drugs for 8 months, he is exhibiting trauma-related and depressive symptoms.
Demographic information
Include age, gender, ethnic background, socioeconomic status and any other information you have.
e.g. Joe Smith is a 17 year old Caucasian male. He reports being of low socioeconomic background and stated most of his family, “struggles with poverty.”
· Current living situation
· Where and with whom does the client live? Include any relevant information.
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e.g. Joe Smith currently lives with his mother and step-father. He was recently discharged from a residential substance abuse program, where he lived for 3 months. Prior to this treatment program, Joe was living on the streets and at friends’ homes for nearly one year, while actively using cocaine and alcohol. He has been out of treatment and living back with his mother and step-father for 5 months. He stated, “It’s not a super nice place but it feels good to be home, to have a place to sleep every night.”
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· Birth and developmental history
· Include here any known aspect regarding: (a) the client’s mother’s pregnancy (planned or unplanned, with or without support, teenage mother, etc.) (b) developmental milestones, problems or concerns; (c) history of learning problems, etc.
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e.g. Joe reported that his mother “was addicted to cocaine when she was pregnant with me.” Although his mother reportedly became sober before Joe turned one, he has experienced the effects of substance exposure in utero. Joe stated he was diagnosed at a young age with a learning disorder and attention deficit disorder.”
· School and social relationships
· This section should include information on social functioning, friends and other supports.
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e.g. Joe describes himself as “an outcast” at school. However, he also reported having deveral close friends. He is especially close with a male, John age 17 and a female, Mary age 18 he met in treatment. Joe stated he feels he “can tell Mary anything.”
Here is an example of how you can include citations in your study:
Joe demonstrates emotional and behavioral concerns and is socially isolated, which are risk factors for disruptions in developmental outcomes of adolescence, such as engaging in healthy social relationships and individuation (Zastrow & Kirst-Ashman, 2014).
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Family members and relationships
This section should include important family relationships, conflicts, supports.
When Joe’s younger sister died in a car accident 2 years ago, Joe immediately withdrew from the rest of his family. He once had a very loving, supportive relationship with his mother. Joe stated, after his sister died his mother, “cried for days and days and never left her bed.” Joe stayed away from home and distanced himself from other family members, as well. He stated, “I didn’t want to think about her. I wanted to run away.” It was at this time, Joe started using drugs and alcohol heavily.
Health and medical Issues (including psychological and psychiatric functioning, substance abuse)
This section should include any current or historical medical problems, psychological/psychiatric problems, previous and current diagnoses, substance use/abuse, smoking, eating behaviors, etc.
· Spiritual development
· This section should focus on client identifies the role of spirituality in his/her life.
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· Social, community, and recreational activities
Include here any activities, groups, clubs, organizations, etc. the client is involved in.
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· Client strengths, capacities, and resources
This is a very important section. Review here client’s strengths and abilities, resources and supports.
Joe has experienced many challenges in his life, yet he demonstrates resilience despite his exposure to adversity. Joe is an engaging young man who is polite and well-spoken. Despite his learning problems, living on the streets and going to residential treatment, Joe passed all of his classes this school year and is being advanced to the 12th grade.
After addressing the 10 categories, answer the following supplemental questions.
· 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
· 2. Several theories are woven through this case study—Maslow’s Hierarchy of Needs, Systems Theory, Engagement and Assessment Skills. Explain which of the theories you used to guide your practice.
· 3. Describe the challenges faced by the client(s)—for example, drug addiction, lack of basic needs, victim of abuse, new school environment, etc.
· 4. Describe the identified strengths of the client(s).
· 5. Explain the agreed-upon goals to be met in order to address the concerns.
· 6. Did you have to address any issues around cultural competence? Did you have to learn about this population/group prior to beginning your work with this client system? If so, what type of research did you do to prepare?
· 7. What, if any local, state, or federal policies could (or do) impact this situation?
· 8. How would you advocate for social change to positively impact this case?
· 9. Are there any legal/ethical issues present in the case? If so, what were they and how were they addressed?
· 10. How can evidence-based practice be integrated into this situation?
· 11. Is there any additional information or material you think is important to the use of the case?
12. Provide any personal reflection regarding the case that you think would be relevant to the course.