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swk_304_-_assessment_form_0 swk_304_-_assessment_form_sample_joe_1
This is a Social Work field Assignment. This paper is from the Social Work field and is about Client Assessment/ Client Assisment form based on a video clip that is about 30 min. lenght. You must watch this clip that I will provide you with link for. the clip is about 30-40 min in lenght but for some reason is devided into 5 part. You must watch all 5 parts of this video. This video is about a girl named Kristin who is in her early 20’s. She is alcoholic, heroin addict, prostitute. You are to watch this video and I will attach the Assessment form that you are to fill out. I will also attach a sample of this form so you can view an example of how this form is completed. The form is asking to complete Description of the problem that Kristin is facing, Family history, Intellectual functioning, Social functioning, Occupational functioning. You are to do Assessment Form on Kristin. This the your video based on Kristins Life: Part 1: http://www.aetv.com/intervention/video/?bcpid=53411497001&bclid=62635706001&bctid=49419622001&baseURL=%2Fbcconfig%2FPlayer%2F3Tier%2FIntervention_3Tws%2Fconfig-xml%2F&baseDIR=%2Fbcplayers%2FPlayer%2F3Tier_ws%2FbaseDIR%2F Part 2: http://www.aetv.com/intervention/video/?bcpid=53411497001&bclid=62635706001&bctid=49423954001&baseURL=%2Fbcconfig%2FPlayer%2F3Tier%2FIntervention_3Tws%2Fconfig-xml%2F&baseDIR=%2Fbcplayers%2FPlayer%2F3Tier_ws%2FbaseDIR%2F Part 3: http://www.aetv.com/intervention/video/?bcpid=53411497001&bclid=62635706001&bctid=49419627001&baseURL=%2Fbcconfig%2FPlayer%2F3Tier%2FIntervention_3Tws%2Fconfig-xml%2F&baseDIR=%2Fbcplayers%2FPlayer%2F3Tier_ws%2FbaseDIR%2F Part 4: http://www.aetv.com/intervention/video/?bcpid=53411497001&bclid=62635706001&bctid=49421328001&baseURL=%2Fbcconfig%2FPlayer%2F3Tier%2FIntervention_3Tws%2Fconfig-xml%2F&baseDIR=%2Fbcplayers%2FPlayer%2F3Tier_ws%2FbaseDIR%2F Part 5: http://www.aetv.com/intervention/video/?bcpid=53411497001&bclid=62635706001&bctid=49415118001&baseURL=%2Fbcconfig%2FPlayer%2F3Tier%2FIntervention_3Tws%2Fconfig-xml%2F&baseDIR=%2Fbcplayers%2FPlayer%2F3Tier_ws%2FbaseDIR%2F i will attach the Client Assessment form and also i will attach a sample so you can view how this order should be completed.
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
1
0, 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
PAGE
1
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
1
2-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 |
|||
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Drowsy |
Labile |
||||
|
Hyper-alert |
Irritable |
||||
|
Intellectual |
Mood |
Depressed |
|||
|
Above avg |
In normal range |
Anxious |
|||
|
avg. |
Angry |
||||
|
Below avg |
euthymic |
Fearful |
|||
|
Borderline |
|||||
|
Mentally Retarded |
Rapid cycling |
||||
|
Memory: Short term |
Psychmotor |
Thought Process |
|||
|
Intact |
|||||
|
Impaired |
Tense/rigid |
Incoherent |
|||
|
Long-term |
Tremor |
Dissociative |
|||
|
Underactive |
Obsessive |
||||
|
Overactive |
Narrow |
||||
|
Insight |
Withdrawn |
Concrete |
|||
|
Adequate |
Circumstantial |
||||
| Poor |
Thought Content |
Tangential |
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Thought blocking |
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|
Delusions |
Flight of ideas |
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Hallucinations |
Loose association |
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Other critical shifts in mood/cognition/intellect: |
|||||
|
Motivation to participate in treatment: |
|||||
|
Client(s) demonstrates a readiness to participate in treatment:
IP: FORMCHECKBOX |
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|
Client(s) demonstrates a willingness to participate in treatment: IP: FORMCHECKBOX |
|||||
|
Client(s) demonstrates an ability to participate in treatment:
IP: FORMCHECKBOX |
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
PAGE
1
