Psychosocial Assessment Outline: Use the headings and bullet points from this outline to organize your Psychosocial Assessment paper

I. DESCRIPTION and PRESENTING PROBLEM(S)

a. Identify client system (person, family, group, organization, community)

b. Specify the presenting issues of concern as outlined by the client and significant others .

Suggestions for writing the narrative:

In this section, describe the presenting issue or issues of concern as identified by the client or responsible party (e.g., parent, guardian, judge, researcher, or medical doctor). Clearly identify the source of the information and summarize the origin, development, and status of the issue. Quote significant words and phrases chat help to describe needs, issue, concerns, or goals. In this section, outline how social services came to be sough t or required at this time. Also, if identified, record the initial, desired outcome of the social service as envisioned by the client or responsible party. Unless the situation is of such an urgent or life threatening nature char you are required to take action immediately, postpone your own review of issues and goals until you and the client have under­ taken a more thorough exploration and assessment. (Cournoyer, pg. 279).

c. Assets and resources available to support the client

Suggestions for writing the narrative:

In this section record information concerning strengths, assets, and resources available within the client system. Competencies, social supports, successes and life lessons may be noted as well as specific resources such as the involvement of concerned significant others, financial resources, optimistic attitudes, or high energy levels. Identify the source of this information about assets and resources. If possible quote specific descriptive words and phrases.

II. DATA COLLECTION on SOCIAL HISTORY

a. Summarize the history of the problem

1) Reasons for and circumstances of referral or request for help as stated by the client, family, and others involved

2) Previous coping efforts and their effect

b. Describe strengths, weaknesses, patterns and characteristics in

1) Person System

· Physical/biological abilities and limitations

· Mental/cognitive abilities and limitations

· Psychological/emotional factors

· Life stages/developmental milestones and issues

· Alcohol/drug use

Suggestions for writing the narrative:

In this section, include information that helps describe the client further. Whenever possible, use information that comes from clients themselves and your direct observations, rather than from you r inference. Also, identify the source of the in­ formation (e.g., “Client stated that he had ‘just had his 32nd birthday.”‘ Or, “I observed that the client walked with a limp”). Whenever possible, quote significant words or phrase that the client uses in self-description.

Information based on your r own observations of clients, such as their approximate height and weight, physical appearance, striking or characteristic features, speech patterns, and clothing may be included in this section. Ensure, how­ ever, that such information is actually relevant for the purpose of assessment, and note that it is based on your own observation.

Include attention to both the current abilities and psychological/emotional factors as well as prior events or experiences. Include details when possible for prior events such as hospitalizations, surgeries, mental health treatment, known diagnoses, use of medications, etc. Also include a description of any significant illnesses, injuries, disabilities, and current physical health and well-being.

Include descriptions of the clients’ developmental history such as the nature of their birth, achievement of developmental milestones, significant events or experiences that occurred during the infancy, childhood, adolescent, and adult development process.

2) Environmental systems

· Family/significant others

In this section, describe the client’s family and household, or primary social system. If you have not included them else­ where, include name, age, and telephone numbers and

addresses of significant persons.

· Community context

In this section, describe the community system within which the identified client functions. Indicate the source of the information and include systems such as school, work, medical, recreational, religious, neighborhood, ethnic, cultural, and friendship affiliations whenever appropriate.

The eco-map is an especially valuable tool for presenting the family and community context information and can be included within this section. If you want to try out creating an eco-map you can download a trial version of free software that will help you create one quickly here: http://www.smartdraw.com/ecomap/ecomap-software.htm

· Work, education or other meaningful roles

· Social support network

· Financial

· Spiritual/religious involvement

Describe educational history, history and/or current legal system involvement, issues of custody or guardianship as relevant, employment and military history or volunteer experiences. Summarize current and past religious and spiritual affiliations and their meaning and significance for the client.

· Critical events

Summarize events or situations that might have been significant in some way. Identify critical liberating, empowering, or growth- enhancing processes and events such as successes, accomplishments, achievements, and experiences that may have enhanced psychosocial functioning. Also identify critical events such as violence, abuse, rape or molestation, suicides or suicide attempts, victimization, oppression, and discrimination chat may have had traumatic effects. Describe how these experiences affected the client.

· Other relevant ecological contexts (e.g., place of employment, faith community, agency setting, rural/urban)

c. Issues of difference as these affect the problem, problem definition, understanding, client worker relationship, resources, attitudes, and acceptance of help

· Ethnic

· Racial

· Cultural

· Religious

· Gender

· Age

· Socioeconomic status

· Rurality

III. ASSESSMENT FORMULATION

a. What problems does the client identify during assessment?

b. What additional problems do you identify during assessment?

c. What bio-psycho-social and environmental factors are causing or contributing to the presenting problem and other identified problems/issues?

d. What strengths or weaknesses exist in the client system(s) that may affect the intervention processes?

e. What environmental and client factors may affect the availability and acceptance of help?

f. What are the problems to be “worked” as mutually decided by the client and worker?

IV. THEORY INTEGRATION

a. In about one-half to one page describe the theoretical approaches that informed your formulation.