Integrative Client Systems Assessment
Client Systems Biopsychosocial Assessment Outline
Please Note: A biopsychosocial assessment must be completed on every client assigned to the student. All items on this outline must be completed for each assessment. This matrix must be completed for the client selected for the SW 489 Fall Field Assignment. You must seek the client’s permission to participate in this assignment. All identifying information is to be changed for purposes of maintaining confidentiality. This Assessment and Case Management Plan Paper will be handed in to the assigned Field Faculty on the due date. Select the client in consultation with your field instructor. The paper can be written in narrative form, or student may fill in the blanks of the following matrix. All areas on the matrix must be addressed, in either form.
Student Name:____________________________________________________ Date_______________
Field Instructor Signature___________________________________________ Date_______________
Client Systems Assessment Worksheet
Note: This form will be used to facilitate completion of biopsychosocial assessments.
|Identifying information |
|Name |
|Age, Sex, Race |
|Ethnic background |
|Current employment |
|Marital status |
|Household composition and circumstances (current living situation) |
|Micro level, Mezzo level, Macro level factors |
|Initial Presentation summary: |
|Appearance, orientation |
|Presenting Problem |
|Problem as reported by the client |
|Problem as reported by the referring person(if applicable) |
|Who made the initial contact |
|Onset of the problem, duration, severity |
|Micro level, Mezzo level, Macro level factors |
|Brief History |
| |
|A. Family Background including inter-generational themes, family dynamics, cultural assessment |
| |
|1. Please prepare one of the following: ecomap , culturagram, or genogram |
|2. Risk assessment(suicide, homicide, violence, child abuse, domestic violence, substance abuse) 3. Developmental/ |
|medical history |
|4. Relevant medical &/developmental history |
|5. Micro level, Mezzo level, Macro level factors |
|Current Functioning |
| |
|A. Current Stressors |
|B. Relationships: family, friends, co-workers |
|C. Adequacy of Role Functioning |
|D. Coping and Adaptive skills (strengths) |
|E. Barriers, risks affecting the problem |
|F. Micro level, Mezzo level, Macro level factors |
|Summary |
| |
|Overview of the current |
|Issues |
|Stressors |
|Strengths |
|Initial Steps Toward a Solution |
|Micro level, Mezzo level, Macro level factors |
|Student Self Assessment |
|A. Ethical dilemmas |
|B. Counter transference issues |
|C. Social work roles and techniques you used during the initial phases |
Biopsychosocial Assessment 8-07
CASE PLANNING WORKSHEET
|CONCERN/ ISSUES TO BE ADDRESSED |GOALS/SPECIFIC ACTIVITIES |TARGET DATES |NOTES, COMMENTS, PROGRESS |
| |Include Person Responsible for Each Activity | | |
| |Identify each activity/step that will occur | | |
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(The following section is included for demonstration purposes, and is not required)
Client Signature Date Staff Signature Date Review Dates
RISK ASSESSMENT WORKSHEET
|Suicidal
Ideation |Homicidal
Ideation |Physical
Aggression |Suspected Child Abuse/Neglect |Domestic
Violence |Elder
Abuse |Substance
Abuse |Psychotic
Thought
Processes | |Past Issues: onset, duration, severity | | | | | | | | | |Current Risk Rating
| | | | | | | | | |Method of Assessment
| | | | | | | | | |Actions Taken
| | | | | | | | | |
Ratings:
0 = Not applicable
1 = Minimal risk
2 = Low risk
3 = Medium risk
4 = High risk: requires immediate intervention
Adapted from Dr. Sally Mathiesen – Revised by LNewell 8/08
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