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hn330_u6_sample_assessment_form.pdf
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Course: HN330
Unit 6
Assessment Form (To complete this form, enter data within the brackets. For questions that require a yes or no answer,
input “x” by the choice answer.)
Client Name: Sarah Freeman
Date of Birth: 11/22/1976
Date of Assessment: 5/26/2015
Presenting Situation: (Use this section to describe the client‘s presenting situation. Specifically address
what the client is requesting in terms of assistance, services, and change objectives/goals. As much as
possible, use the client‘s own words in this section.) Sarah is a 38-year-old stay-at-home mom. She
is requesting help for what she believes is “depression.” According to Sarah, she was first
diagnosed with depression in 2007 after she had her first child. Sarah now has 5 children
ranging in age from 6 months to 8 years. She states that the “feelings of hopelessness” have
become gradually more intense with each child. She also reports that she is struggling to
care for her 5 children and that she feels “extremely guilty” about that. Sarah describes her
depression as an “inability to engage my children throughout the day” and a “constant
feeling of extreme exhaustion and hopelessness.” She also states that “I have lost interest in
going out and talking with friends.” According to Sarah, she is here because her husband
“insisted that I get help.” He expressed concern to Sarah about how her condition is affecting
her, their marriage, and their children. Their oldest daughter allegedly asked them what she
did to “make mommy so sad.”
Strengths and Resources: (This is a very important section. Help the client brainstorm personal
strengths and resources in their environment that will help them make the changes they desire.)
Sarah has an Associate’s degree in Early Childhood Education.
Sarah’s husband is loving and supportive of her.
Sarah has a network of friends and family who are willing to help her.
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Sarah is in good physical health.
Sarah’s husband has a good job that allows her to stay home and care for the children.
Sarah has previously attended play groups and parent support programs at an agency in her
community.
Sarah recognizes that there was a time where she felt like a motivated and talented person.
Potential Barriers: (This is another critical area to explore with the client. Help them think about barriers
to achieving their change goals — barriers that already exist as well as barriers that may come up as they
begin to work toward their goals. You do not have to solve them here; just identify them. Explain to the
client that their case manager will come back to these barriers when they work with the client on
developing their individualized service plan.)
Sarah states that a potential barrier could be her lack of energy.
Sarah’s husband travels often for work and leaves her alone to care for their 5 children for
days at a time.
Sarah states that she feels overwhelmed by the tasks that she has to do on a daily basis for
herself and her children.
Sarah claims to feel “ashamed” of herself for not utilizing her degree.
Sarah’s husband is making the payments for “my” school loan, further claiming, “I should be
paying those payments with money I make.”
Culture and Language Considerations: (Are there any particular culture or language issues or needs
that the client wishes you to be aware of? These may not be apparent, so you need to ask in a supportive
and welcoming way if there are special or unique things about them or their family that they want you to
know. Also ask if they have any special learning issues or needs regarding written or verbal
communications.)
Sarah’s 8-year-old son was diagnosed with autism at the age of 3. He receives special
education services through the public school system. Sarah is requesting additional
assistance in caring for him.
Current Client Involvement with Other Agencies and Services:
Agency
Contact Name/Phone
Service
Dates of
Service
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Public School System Jim Smith/800-223-4455 Special Ed. Services for son 2012–2015
Family Place Missy Clayton/555-1234 Play groups/Parent Support 2012–2013
Assessments of Client Domains: (Briefly describe the client‘s status in each of the following domains. If
they indicate none or choose not to answer a particular item, just note ―client declines at this time.‖ This
is a valid option for any of the questions and information requested in this assessment. Case managers
should never force a client to respond to something that makes them uncomfortable.)
Family: Sarah is married to John. They have 5 children: Samuel (6 months), Mark (2½ years), Claire (4
years), Kristy (6 years), Jack (8 years).
Sarah‘s parents live about 8 hours away and try to visit often. John‘s parents live nearby and offer to help,
but do not have much time to actually help out.
Social: Sarah reports that she does not participate in any social activities at this time. She previously
attended playgroups and parenting programs at an agency in her community called The Family Place.
Spiritual: Sarah describes herself as ―religious‖ but that she currently does not attend church. She states
that it is too difficult to get everyone ready on Sunday morning.
Housing: Sarah and her immediate family live in a four bedroom home.
Employment: Sarah is currently unemployed. Before having children, Sarah was a teaching assistant in a
preschool.
Access to health and dental care: Sarah and her family have medical and dental insurance.
Transportation: Sarah and her family have reliable transportation.
Hobbies and recreation: Sarah states that before she had her children that she enjoyed running, painting,
and writing short stories. She previously belonged to a women‘s writing group.
Other
Current Medications:
Name/Dosage: None
Side effects:
Medication allergies:
Prescribed by:
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Safety and Trauma History:
Are you safe in your current living situation? Yes X No
Do you feel threatened in any way? Yes No X
If yes, describe:
Are you now, or have you in the past, experiencing trauma of any kind? Yes No X
If yes, check all that apply:
Emotional/Psychological
Sexual
Physical
Provide a brief description of this and your present status. Include a brief statement of any previous
treatments or services you have received for this trauma(s) and whether or not you have any remaining
symptoms or issues you would like help with.
If applicable, do you have a safety plan? Yes No X
Do you need immediate help today to gain safety? Yes No X
Client’s Legal History: No Legal History
Suicide/Homicide Risk Evaluation:
Client‘s self-rating of suicide risk: 1-None X 2 - Slight 3 - Moderate 4 -
Extreme/Immediate
Client‘s self-rating of becoming violent: X 1-None 2 - Slight 3 - Moderate 4 -
Extreme/Immediate
Client‘s self-rating of homicide risk: X 1-None 2 - Slight 3 - Moderate 4 -
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Extreme/Immediate
Self-harm Risk Evaluation:
Have you ever cut yourself or purposely injured yourself in any way?
1 – Never
X 2 – Once
3 – Occasionally
4 – Frequently
Safety Plan Based on Client Risk Self-Assessment: (You must complete this section if the client rates
any of the previous areas as a 2, 3, or 4. Describe what the client reports and their assessment of their
current level of risk or safety. If they have a safety plan, briefly describe it here.) Sarah states that she
“cut my wrist with a dull knife one time” after her first child was born. She also reports that
she has thought about suicide, but knows that it is “not an option for me” due to “my children
and my faith.” Sarah is close with her mother and reaches out to her when she needs
someone to talk with when her husband is working. Sarah also acknowledges that she
“would ask for help” and now knows that she can reach out to her case manager and
counselor. She denies having present suicidal ideation.
Client Status (caseworker observation of client report)
Appearance:
age appropriate X
well groomed X
disheveled/unkempt
other – explain
Orientation (Is client aware of the following?):
where they are X
why they are here X
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day and time X
their situation X
current events X
Behavior/Body Language:
open
good
limited avoidant
none
relaxed/calm
restless
rigid
agitated
slumped posture X
tense
tics
tremors
other – explain
Motor Activity:
full ability X
minor impairment
serious impairment
catatonic behavior other-explain
Manner:
friendly
trusting
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cooperative X
nervous X
withdrawn
playful
evasive
guarded
quiet
passive
defensive
hostile
agitated
demanding
Speech:
clear X
understandable X
incoherent
rapid
quiet
loud
slurred
slow
Mood:
appropriate (considering presenting situation)
depressed X
irritable
anxious
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euphoric
fatigued
angry
expansive
unable to evaluate – explain
Affect:
appropriate (considering presenting situation)
warm
welcoming
tearful X
blunted X
constricted
flat
labile
excited
anhedonic
Sleep:
excellent
good
fair
poor
increased
decreased
initial insomnia
middle insomnia
terminal insomnia
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client reports concern about sleep pattern X
Appetite:
excellent
good
fair X
poor
increased
decreased
weight gain
weight loss
client reports concern about appetite or weight
Thought Process:
logical and well organized X
illogical
flight of ideas
circumstantial
loose associations
rambling
obsessive
blocking
tangential
spontaneous
perseverative
distractible
Thought Content:
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appropriate (considering presenting situation) X
delusions
paranoid delusions
distortions
thought withdrawal
thought insertion
thought broadcast
magical thinking
somatic delusions
ideas of reference
delusional guilt
grandiose delusions
nihilistic delusions
ideas of inference
unable to evaluate – explain
Perceptions:
appropriate (considering presenting situation)X
illusions
hallucinations
depersonalization
derealization
unable to evaluate – explain
Judgment:
intact X
age appropriate
impulsive
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immature
impaired
mild
unable to evaluate – explain
client reports
Insight:
intact X
limited
very limited
fair
none
aware of current situation
understands internal and external factors involved in current situation
unable to evaluate – explain
client reports
Memory:
intact X
impaired
immediate recall
remote
unable to evaluate – explain
amnesia (type of amnesia)
Cognitive functioning:
no issues noted X
issues noted – describe
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client reports
Substance Use/Abuse:
Type
Amount
Used
How Taken
Duration
Frequency
Date of last use
Tobacco
None
Alcohol
1–2 glasses of
wine
For the past 5
years
5 days a week 5/26/2015
Illicit Drugs
None
Prescription
Drugs
None
OTC Drugs
None
Other
None
Experiencing:
Withdrawal Yes No X
Blackouts Yes No X
Hallucinations Yes No X
Vomiting Yes No X
Severe depression Yes No X
DTs and shaking Yes No X
Seizures Yes No X
Other Yes No X If yes, describe:
Patterns of Use:
Do you use more under stress? Yes X No
Do you continue to use when others have stopped? Yes No X
Have you lied about consumption? Yes X No
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Have you tried to avoid others while using? Yes X No
Have you been drunk/high for several days at a time? Yes No X
Do you sometimes neglect obligations when using? Yes X No
Do you sometimes use more than you intended? Yes X No
Are you finding you need to increase use to get the effect you desire? Yes No X
Have you tried to hide consumption? Yes X No
Do you sometimes use before noon? Yes No X
Do you find you cannot limit use once begun? Yes No X
Have you failed to keep promises to reduce use? Yes No X
Do you arrange your day around your substance use? Yes No X
Have you attempted to reduce or stop before?
Yes
No X
What happened?
Describe the circumstances that usually lead to a relapse for you:
Do you want to reduce or stop using the substances described above?
Yes X
No
Do you have depression or other mental health issues that you believe affect your use of substances?
Yes X
No
If yes, please describe: Sarah states; ―I deal with my ‗depression‘ with wine.‖
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Are you presently involved in AA/NA?
Yes
No X
What are your goals for change in this area? “I would like to stop feeling as though I need to
numb myself with alcohol to deal with these horrible feelings I experience. There has to be
other ways in which I can feel better.”
DSM 5 Diagnostic Impression: (Diagnostic Impression means an interpretive statement based upon
previous and current evaluative data. A diagnostic impression may or may not make reference to DSM
criteria): Depression
Clinical Summary: (Using the information you have gathered at this point, provide a brief summary of
the presenting issues, client strengths and needs, any immediate risks, and the client‘s goals for change.
You will be reviewing this assessment and your summary and recommendations with the client and with
your clinical supervisor so be sure to write in terms the client can understand and relate to (avoid
technical jargon) and maintain a strengths-based and empowerment perspective.) Sarah is a 38-year-old
stay-at-home mom of 5 children, one of which has been diagnosed with autism. She is struggling
with what she reports as being “depression” and has been using alcohol to cope with her situation
for about 5 years. She states that “my depression began approximately 8 years ago, when my first
child was born.” Sarah has had a lack of energy and has neglected some of her parenting
responsibilities, which she feels “extremely guilty” about. Sarah’s affect was blunted and she
appeared tearful. Sarah denies suicidal and homicidal ideations; however, admits to previous
attempt 8 years ago. Sarah is aware of her family and community support and resources, but has
not had the energy to reach out. Sarah would like to feel more connected to her family, friends, and
community. She would also like to explore alternatives to alcohol in coping with her depression.
Finally, Sarah would like some additional assistance in caring for her 8-year-old son who was
diagnosed with autism.
Recommendations: (including specific service recommendations)
Recommend psychiatric evaluation in order to confirm diagnosis of depression and referral for 6
sessions of individual counseling, initially to address depression and alcohol use.
Recommend that Sarah attend The Family Place 1 time per week to take advantage of playgroups
for her younger children and parent support groups.
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Recommend that Sarah get connected with in-home services for her son who has been diagnosed
with autism. Also, recommend support group for parents with children with autism.
Disposition: (clearly describe the next steps and what this client can expect next from your agency. If you
have already arranged an intake with a case manager or a counselor, include the name of the worker, their
credentials, and the date and time of the next appointment.)
Psychiatric Evaluation is scheduled on 6/1/2015 with Susan Davies.
Appointment with case manager is scheduled for 6/5/15 with Jennifer Hutras to further develop an
Individualized Service Plan.
Client Signature: Sarah Freeman
Date: 5/26/2015
Legal Guardian‘s Signature (if one is assigned or if client is under 18):
Date:
Case Manager Signature: Jennifer Hutras
Date: 5/26/2015
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