This assignment will examine clinical strategies utilized in advanced social work practice with individuals and/or families. Your instructor will provide a case study. This is a professional paper; it should be at least 15-20 pages in length (not including the cover page or references), typewritten, one and a half spacing and in APA style of writing.
Outline
Introduction
Engagement
- Discuss engagement skills with this client.
Assessment
- Specialized assessments including a biopsychosocial-spiritual assessment (include it in the appendix), mental status exam, specific assessment tools utilized to help identify and define the problem/s, a description of the client’s interpersonal behavior and emotional processes, that either support or discredit your assumptions, discussion of cultural influences and DSM 5 diagnosis with qualifying examples. Also, include any other screening/assessment tools to evaluate the problem.
Intervention
- Specialized intervention strategies, techniques and modalities including a behavior plan (with goals and objectives that are measurable and observable), cultural and human diversity issues impacting treatment.
Termination
- Identify indicators that treatment is in the termination stage and specific strategies how to terminate treatment. Include issues related to closure, celebration, follow-up plans, processing feelings and referrals.
Evaluation
- Strategies and at least one instrument to evaluate the treatment program (beginning, middle, and ending). The evaluation must identify how assessments are used to determine evaluation and goal attainment.
Conclusion
Biopsychosocial Assessment
Demographic data
DATE:
CLIENT NAME:
DOB:
AGE:
GENDER:
ADDRESS:
PHONE (HOME/CELL/WORK):
START TIME:
DURATION:
Primary method of communication:
Referral source:
Funding source:
Completed assessment with:
Current symptoms
Cognitive functions:
Dangerous behaviors & immediate threat to personal safety:
Indicators of personality disorder:
Emotional/psychiatric history
Prior outpatient treatment:
Prior inpatient treatment:
Prior residential treatment:
Date of most recent psychiatric assessment:
Current psychotropic medication:
Prior psychotropic medication:
Family members’ treatment history
Has any family member had outpatient treatment?:
Has any family member had inpatient treatment?:
Has any family member used psychotropic medications?:
Family history
Family of origin
Present during childhood:
Parents’ current marital status:
Describe childhood family experience:
Emancipation from home:
Special circumstances in childhood:
Current family
Marital status:
Intimate relationship:
Relationship satisfaction:
List all persons currently living in client’s household:
List all children not living in client’s household including frequency of visitation:
Describe any past or current significant issues in intimate or immediate family relationships:
Client abuse history
Description of abuse etc.:
Concerns/needs/issues/services accessed/linkages needed:
Medical history
Current medical problem(s):
Significant medical history:
List all non-psychotropic medication currently taken:
Nutritional development:
Concerns/needs/issues/services accessed/linkages needed:
Substance use history
Substance abuse history
Family substance abuse history
Concerns/needs/issues/services accessed/linkages needed:
Developmental history
Physical development:
Chronological age:
Prenatal history:
Birth:
Delayed developmental milestones:
Sensorimotor functioning & motor development:
Concerns/needs/issues/services accessed/linkages needed:
Educational development
Last/current grade completed and school attended:
Elementary, middle/high and college/vocational training schools:
If received special education services:
Concerns/needs/issues/services accessed/linkages needed:
Developmental history (child and adolescent client)
Emotional development:
Mood:
Emotional/behavior problems:
Concerns/needs/issues/services accessed/linkages needed:
Cognitive development:
Cognitive problems:
Concerns/needs/issues/services accessed/linkages needed:
Social development:
Social problems:
Concerns/needs/issues/services accessed/linkages needed:
Socio-economy history
Current living situation:
Daily living skills:
Social support system:
Sexual history:
Military history:
Type of discharge:
Employment:
Financial situation:
Concerns/needs/issues/services accessed/linkages needed:
Legal history/status:
Cultural/spiritual/recreational status:
Spiritual/religious affiliation:
Cultural/ethnicity affiliation:
Community involvement/recreational status:
Guardianship status:
Mental status examination
Appearance:
Manner:
Attitude:
Consciousness:
Affect:
Prevailing mood:
Thought processes:
Content:
Associations:
Speech:
Faculty orientation:
Attention span/concentration:
Perception:
Intellectual functions:
Memory deficits:
Judgment:
Insight:
Additional comments:
Client strengths and weaknesses
Client’s strengths:
Client’s weaknesses and obstacles:
Client treatment goals and barriers
Client preferences:
Barriers to achieving client preferences:
Duration:
Additional info:
Summary of presenting problems and recommendations
Summary of presenting problem:
Current and past level of functioning:
Clinical impression:
Justification for issues not addressed in treatment:
Conclusions and recommendations:
