Social Work: Client Assessment based on Video

IDENTIFYING INFORMATION

Client’s name : First:Kriten Last: Social Worker: Yonka Valkova

Persons interviewed (check all the apply):

FORMCHECKBOX Identified client FORMCHECKBOX Parent: mother FORMCHECKBOX Others: Friend-Lane

FORMCHECKBOX Spouse FORMCHECKBOX Grandparents FORMCHECKBOX Other professionals

FORMCHECKBOX Parent: father FORMCHECKBOX nonrelated significant other FORMCHECKBOX Other siblings

Family composition (List name with age)

· Spouse/partner: /Age:

· Ex spouse: Sadie’s Father /Age: 20’s-30’s.

· Child:Sadie /Age: 5 years old.

· Child: /Age:

· Child: /Age:

· Grandparents: /Age:

· Others: Janet- (Mom) /Age: mid 50’s.

Erin- (Sister) /Age: in early, mid 30’s.

Aloy- (Aunt) /Age: in mid 50’s.

Peter- (Uncle) /Age: mid 50’s.

Lane- (Roommate) /Age: in early 20’s.

Interview Date: November 10, 2010 Report Date:November 10, 2010

Source of Data : 30-60 minute interview

60-90 minute interview

State agency reports (DCFS, probation, DHS etc.)

School reports

Other:

PRESENTING PROBLEM

Presenting Problem: (Reason for seeking treatment at this time.)

Kristin is alcoholic, heroin addict, prostitute, who smokes weed and cannot control her life.

Also in danger of loosing custody of her child, Sadie.

Brief Description of the problem: (Extent of problem, nature & severity of symptoms, behavior changes, stressors) No more than ½ page

SOCIAL ASSESSMENT (include all of the following)

Family history:(2 paragraphs) (Who is part of the family, including parents, siblings, others, parents’ relationship, cultural and ethnic background, mental health issues, developmental disabilities, substance abuse, parents’ employment history)

Intellectual functioning: (Highest level of education, learning disabilities, history of academic failures or special education), ( 2 paragraphs)

Social functioning: (Current and past romantic relationships – listen for information about the quality of those relationships, including any emotional or physical abuse. Does he/she have friends, close friends? Who does he/she seek support from? Involvement with any community groups.), (2-3 paragraphs)

Occupational functioning: (Employment history, work performance including relationship with supervisors and co-workers, history of termination, current employment), (1-2 paragraphs)

FINANCIAL RESOURCES

No more than 1 page

Check all that apply and insert recipient

Use: IP (Identified client) SP (spouse, partner) C (child)

Identified Client:

FORMCHECKBOX wages/salary FORMCHECKBOX Unemployment FORMCHECKBOX Workman’s compensation

FORMCHECKBOX SSDI or SSI FORMCHECKBOX Trust Benefit FORMCHECKBOX All Kids insurance

FORMCHECKBOX Cash Asst. FORMCHECKBOX Food Stamps FORMCHECKBOX Vets benefits

FORMCHECKBOX Subsidized Housing FORMCHECKBOX Medicaid Ins. FORMCHECKBOX Medicare Insurance

· Describe current job and job stability: (2 paragraphs)

· Describe previous jobs and job stability:

· Education and training:

Spouse/parent:

FORMCHECKBOX Wages/salary FORMCHECKBOX Unemployment FORMCHECKBOX Workman’s compensation

FORMCHECKBOX SSDI or SSI FORMCHECKBOX Trust Benefit FORMCHECKBOX All Kids insurance

FORMCHECKBOX Cash Asst. FORMCHECKBOX Food Stamps FORMCHECKBOX Vets benefits

FORMCHECKBOX Subsidized Housing FORMCHECKBOX Medicaid Ins FORMCHECKBOX Medicare Insurance

· Describe current job and job stability

· Describe previous jobs and job stability:

· Education and training:

Other persons in household:

FORMCHECKBOX Wages/salary FORMCHECKBOX Unemployment FORMCHECKBOX Workman’s compensation

FORMCHECKBOX SSDI or SSI FORMCHECKBOX Trust Benefit FORMCHECKBOX All Kids insurance

FORMCHECKBOX Cash Asst. FORMCHECKBOX Food Stamps FORMCHECKBOX Vets benefits

FORMCHECKBOX Subsidized Housing FORMCHECKBOX Medicaid Ins. FORMCHECKBOX Medicare Insurance

· Describe current job and job stability

· Describe previous jobs and job stability

· Education and training