Social Work: Client Assessment based on Video

IDENTIFYING INFORMATION

Client’s name : First: Joe Last: Social Worker: Deborah Birch-Gaytan

Persons interviewed (check all the apply):

FORMCHECKBOX Identified client FORMCHECKBOX Parent: mother FORMCHECKBOX Others – ex-girlfriend,

FORMCHECKBOX Spouse FORMCHECKBOX Grandparents FORMCHECKBOX Other professionals

FORMCHECKBOX Parent: father FORMCHECKBOX nonrelated significant other FORMCHECKBOX Siblings–half brothers

Family composition (List name with age)

· Spouse/partner: /Age:

· Ex spouse: (Ex girlfriend) Sarah /Age: Early to mid-20s

· Child: Lyla /Age: About 2-years-old

· Child: /Age:

· Child: /Age:

· Grandparents: /Age:

· Others: Father /Age: 50s or 60s

Mother /Age: 50s or 60s

Half brother /Age: about 12-years-old

Half brother /Age: about 9-years-old

Stepfather /Age: 50s or 60s

Interview Date: 11/9/10 Report Date: 11/9/10

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.)

Joe is addicted to heroin, which he injects intravenously.

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

Joe has been using heroin for three years. He spends about $200 a day to maintain his heroin addiction. He uses heroin daily, including before visits with his daughter who is a toddler. At this point Joe states that it takes him five bags (a street measurement of heroin) to get high. He sometimes uses up to 35 bags a day. Joe began smoking marijuana at age 15 and at that time he was also drinking alcohol. By the age of 17 Joe was using LSD, ecstasy and mushrooms. As a teenager he participated in outpatient rehabilitation services for a short time. At age 18 Joe broke into his mother’s safe and stole her credit cards. Reluctantly, Joe’s mother pressed charges and Joe was jailed for one year. He was sober in jail and then again participated in outpatient treatment after he got out of jail. He attended Narcotics Anonymous (NA) meetings. Again he relapsed and has been using heroin since that relapse. Stressors in his life were feeling isolated from his father who had remarried and had two other children and feeling out of place living in the suburbs. These were stressors that Joe stated started his drug use.

SOCIAL ASSESSMENT (include all of the following)

Family history: (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)

Joe is the only son from his mother and father. The family is Caucasian. His parents divorced when Joe was three. His father remarried and had two more sons with Joe’s stepmother. Joe is close to his half brothers. His brothers look up to him, though are both worried about the problems Joe’s heroin addiction are causing for him. When Joe was a young child his father drank alcohol often to the point of intoxication. Evidence suggested that Joe’s father was an alcoholic when Joe was a young child. Father’s alcohol use currently is unclear. Joe and his father have not spoken in a year and a half. Joe’s father obtains information about Joe’s life through his sons. Joe’s mother also remarried when Joe was in high school at which time the family moved from the city to the suburbs. Joe sees his mother fairly often because he lives in one of the houses she owns (though she does not live in that same house with Joe).

Joe has a daughter from his ex-girlfriend Sarah. Their daughter’s name is Lyla. Joe has taken Lyla with him to pick-up drugs in the past, so at this time Sarah does not leave Lyla alone with Joe.

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

Joe has some high school education and may have graduated from high school, though that is unclear at this time.

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.)

Joe dated Sarah, the mother of their child Lyla, for three months at which point Sarah got pregnant. Joe was sober and clean of drugs when he dated Sarah. Two months after Sarah got pregnant Joe relapsed and began using heroin again at which time the romantic relationship between Joe and Sarah ended. Joe and Sarah remain in contact primarily so Joe can maintain a relationship with Lyla who lives with Sarah. At present Joe has few friends and those friends he does have are people who spend time with him when he offers them heroin.

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

Joe works as a tattoo artist, which he has been doing for three years. Joe’s co-workers have noticed a negative change in his behavior at work recently.

Mental health status: (Current emotional and mental health issues, history of current symptoms, date or age of onset, course of symptoms, client’s understanding of what contributed to onset of symptoms, history of treatment, including counseling and medication, and effectiveness of treatment)

Joe meets criteria for Opioid Dependence with Physiological Dependence. His tolerance has increased over time and he needs more heroin now then he did when he began using heroin to achieve the same high. Signs of withdrawal are unclear at this time because Joe has been consistently using heroin in a daily basis. He has tried to stop using heroin in the past, but has relapsed after a period of sobriety. His longest period of sobriety was a year at which time Joe was in jail. Joe uses most of his money to buy drugs and has increased his work hours recently to make more money to buy heroin. Joe’s socializing is all around using drugs. Joe has been using heroin for three years. Prior to using heroin Joe was using marijuana, since age 15 and by age 17 was using LSD, mushrooms and ecstasy in addition to marijuana.

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: Joe is a tattoo artist. He has had this job for three years. His boss and co-workers have expressed some concerns about his work performance recently.

· Describe previous jobs and job stability: No information is known about this.

· Education and training: Attended high school, though it is unclear if he graduated from high school or not.

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

Self-Care (describe present health problems) No more than ½ page

Assessment (max 1 page)

MENTAL STATUS AND COGNITIVE FUNCTIONING

Check all that apply related to: identified client
Appearance	Attitude	Eye Contact
Well-groomed	Cooperative	Direct
Appropriate	Guarded	Intermittent
Disheveled	Suspicious	Fleeting
Poor Hygiene	Indifferent	Nonexistent
Bizarre
Tempo of thought	Attention	Affect
normal	Normal	Appropriate
Rapid	Distractible	Incongruent
Slow	Pre-occupied	Flat
Impulsive	Inattentive	Constricted
	Drowsy	Labile
	Hyper-alert	Irritable
Intellectual	Mood	Depressed
Above avg	In normal range	Anxious
avg.	Anxious	Angry
Below avg	euthymic	Fearful
Borderline	Depressed
Mentally Retarded	Rapid cycling
Memory: Short term	Psychmotor	Thought Process
Intact	Normal	Normal
Impaired	Tense/rigid	Incoherent
Long-term	Tremor	Dissociative
Intact	Underactive	Obsessive
Impaired	Overactive	Narrow
Insight	Withdrawn	Concrete
Adequate		Circumstantial
Poor	Thought Content	Tangential
	Appropriate	Thought blocking
	Delusions	Flight of ideas
	Hallucinations	Loose association
Other critical shifts in mood/cognition/intellect:
Motivation to participate in treatment:
Client(s) demonstrates a readiness to participate in treatment: IP: FORMCHECKBOX yes FORMCHECKBOX no Partner: FORMCHECKBOX yes FORMCHECKBOX no Child: FORMCHECKBOX yes FORMCHECKBOX no Other: FORMCHECKBOX yes FORMCHECKBOX no
Client(s) demonstrates a willingness to participate in treatment: IP: FORMCHECKBOX yes FORMCHECKBOX no Partner: FORMCHECKBOX yes FORMCHECKBOX no Child: FORMCHECKBOX yes FORMCHECKBOX no Other: FORMCHECKBOX yes FORMCHECKBOX no
Client(s) demonstrates an ability to participate in treatment: IP: FORMCHECKBOX yes FORMCHECKBOX no Partner: FORMCHECKBOX yes FORMCHECKBOX no Child: FORMCHECKBOX yes FORMCHECKBOX no Other: FORMCHECKBOX yes FORMCHECKBOX no

Comments regarding mental status: (include duty to warn and injurious behaviors)

Support Resources

Check all that apply for current available support systems

Identified client:

FORMCHECKBOX Family FORMCHECKBOX Community Resources

FORMCHECKBOX Relationships/friends FORMCHECKBOX Spiritual activities

FORMCHECKBOX Cultural identity FORMCHECKBOX Social Service providers

FORMCHECKBOX Hobbies/interests FORMCHECKBOX Other

Describe extent and use of strengths in each area:

     

Describe how you use them to reduce PP and stress related symptoms

     

Others in household:

FORMCHECKBOX Family FORMCHECKBOX Community Resources

FORMCHECKBOX Relationships/friends FORMCHECKBOX Spiritual activities

FORMCHECKBOX Cultural identity FORMCHECKBOX Social Service providers

FORMCHECKBOX Hobbies/interests FORMCHECKBOX Other

Describe extent and use of strengths in each area:

Describe how you use them to reduce PP and stress related symptoms

Others in household:

FORMCHECKBOX Family FORMCHECKBOX Community Resources

FORMCHECKBOX Relationships/friends FORMCHECKBOX Spiritual activities

FORMCHECKBOX Cultural identity FORMCHECKBOX Social Service providers

FORMCHECKBOX Hobbies/interests FORMCHECKBOX Other

Describe extent and use of strengths in each area:

Describe how you use them to reduce PP and stress related symptoms

TENTITIVE DIAGNOSIS WITH RATIONAL:

AXIS I:

RATIONALE:

AXIS II

RATIONALE:

AXIS III:

RATIONALE:

AXIS IV:

RATIONALE:

AXIV V:

RATIONALE

Ethical Considerations and/or dilemmas