Biopsychosocial Assessment Format.

Demographicinformation:age,gender,genderidentity;race/ethnicity;sexualorientation;current employment, marital status; language spoken; socioeconomic status: What entitlements does the client receive (SNAP benefits; food assistance, rental assistance, child support services, career services; assistance with utilities; disability services?)

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Briefmentalstatusexam(i.e.,appearance,attitude,behavior,speech,affect,mood).

Referralinformation:referralsource(selforother),reasonforreferral.Otherprofessionalscurrently involved.

Presenting Problem

Descriptionoftheproblem:Client’sdefinitionoftheproblem/need.Usetheclient’swords.

Historyofthepresentingproblem:Lengthordurationoftheproblem(i.e.,howlonghastheproblem been going on?) What precipitating stressors or events brought on the current problem? What feelings and thoughts have been aroused? How has the client coped so far? Prior attempts to resolve the problem. Who else is involved in the problem? How are they involved? How do they view the problem? How have they reacted? How have they contributed to the problem or solution? Past experiences related to current difficulty. Has something like this ever happened before? If so, how was it handled then? What were the consequences? Previous involvement with social agencies for assistance with the problem. If client is in crisis or considered \”high risk\” (i.e., in danger of harm to self or others, you should describe and offer a brief assessment of the risk).

SWK 650 – Summer 2021 (Rivera)

Background History

Developmentalhistory:fromearlylifetopresent

Familybackground:descriptionoffamilyoforiginandcurrentfamily.Extentofsupport.Familyperspective on client and client’s perspective on family. Family communication patterns. Family’sinfluence on client and intergenerational factors.

Socialfunctioning:Arethereanysignificantfriendships,interpersonalrelationships,supportnetwork? Use of community organizations or resources (e.g., as client, member, volunteer)?Hobbies/leisure involvement

Educationaland/orvocationaltraining:Highestlevelofeducation;Degree/searned;Specialschool/educational talents, challenges, goals

Employmenthistory:Occupation,workhistory,andcurrentstatus(e.g.,employed,unemployed,full-time, part-time; disability). Special training/skills. History of work habits (timeliness, insubordination, ability to fulfill work duties). Reason(s) for leaving (e.g., terminated; history of terminations; relocated)

Military history (if applicable): Is client a U.S. Veteran?

Use and abuse of alcohol or drugs, self and family

Medicalhistory:birthinformation,illnesses,accidents,surgery,allergies,disabilities,healthproblems in family, nutrition, exercise, sleep

Mental health history: previous mental health problems and treatment, hospitalizations, outcomeof treatment, family mental health issues.

Significant events: deaths of significant others, serious losses or traumas, significant lifeachievements

Legalconcerns(ifapplicable):Immigrantstatus,housing,maritalissues,domesticviolence,parole/probation, DWI\’s?

Cultural background: race/ethnicity, primary language/other languages spoken, significance ofcultural identity, cultural strengths, experiences of discrimination or oppression, migrationexperience and impact of migration on individual and family life cycle.

Religion: denomination, church membership, extent of involvement, spiritual perspective, specialobservances

Assessment

Whatisthekeyissueorproblemfromtheclient’sperspective?Fromtheworker’sperspective?

Howeffectivelyistheclientfunctioning?

Whatfactors,includingthoughts,behaviors,personalityissues,environmentalcircumstances,psychosocial stressors (e.g., bereavement, domestic violence), vulnerabilities, and needs seem to be contributing to the problem(s)? Please use systems theory with the ecological perspective as a framework when identifying these factors.

Identifythestrengthscopingability,andresourcesthatcanbemobilizedtohelptheclient.

Assess client’s motivation and potential to benefit from intervention

Recommendations/Proposed Intervention

Problem

Tentative Goals (with measurable objectives and tasks)

One Short-term

One Long-term

Possibleobstaclesandtentativeapproachtoobstacles

SWK 650 – Summer 2021 (Rivera)