Tasks Assessment Write-Up When you are the social worker, you will take the in

Tasks
Assessment Write-Up
When you are the social worker, you will take the information you gather during your work with the
client to write a bio-psycho-social-spiritual-cultural assessment. This is meant to be a thorough and
detailed assessment that consists of the social worker’s observations of verbal and nonverbal behavior and
identification of factors that affect social functioning. Once the situation has been assessed, the social
worker writes a report, which is used to formulate a case plan. You will include an ecomap as part of this
assessment. You have the option to complete this assessment with 1) a client you work with in your field
practicum (in this scenario, please maintain your client’s confidentiality by using an alias and not
using identifying information) or 2) choosing between two different case vignettes that will be provided
by the instructor.
Format
Please type in 12-point font. Use the outline provided to guide you are you prepare your assessment. Note
that sample assessment questions are in italics within the outline to assist you when developing your
assessment. Unless otherwise noted in the outline, the assessment should be written in full sentences and
paragraphs. Please use the headings and subheadings as listed below; they help both you and your reader
to find important information quickly.
Evaluation Guide
• SOAP Note: (15 points)
o Mechanics: Communicates verbal or written information in a manner that is clear to
follow and focused on the chosen topic. Grammatical mistakes are minimal and length is
within the given guidelines. Please note that 4-6 sentences is equivalent to a paragraph (3
points).
o Tone: Word choice is respectful of individuals and does not include judgements of
individuals’ behaviors. Language used is specific and moves beyond generic, subjective
terms such as good, bad, well, many, a lot, often (5 points).
o Adherence to sections: Note is well-organized, with a clear distinction between what the
social worker and individual discussed in the session, what the social worker, the
worker’s assessment of the individual’s progress and plans for the next meeting (7
points).
• Narrative Assessment: (55 points)
o Mechanics: Communicates verbal or written information in a narrative manner that is
clear to follow. Headings align with the given outline. Grammatical mistakes are minimal
and length is within the given guidelines (5 points).
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o Tone: Word choice is respectful of individuals and does not include judgements of
individuals’ behaviors. Language used is specific and moves beyond generic, subjective
terms such as good, bad, well, many, a lot, often (15 points).
o Adherence to sections: Assessment is well-organized, with a clear distinction between
each section (35 points).
§ Identifying Information (2 points)
§ Descriiption of Person System, Family/Household/Primary Social System, &
Ecological System (12 points)
§ Referral Source and Process (2 points)
§ Presenting Problems and Goals (2 points)
§ Social History (12 points)
§ Prior Services (2 points)
§ Social Worker’s Impressions (3 points)
• Genogram: (15 points)
o Structure includes at least three generations of family members and is structured with
generations aligned horizontally and biological relationships clearly depicted within
assigned format (5 points).
o Information about each member is thoroughly completed and includes information such
as physical/mental health, spirituality, substance use, and other information as
appropriate (5 points).
o Family relationships are indicated and critical incidents noted: 5 points
• Ecomap: (15 points)
o Structure is within assigned format (5 points)
o Information about each person/organization/community is thoroughly completed (5
points)
o Relationships are indicated (5 points)
Bio-Psycho-Social-Spiritual-Cultural Assessment Format/Outline
1) Client Identification & Contact Information—In this section, provide information that helps to
identify the client and other relevant persons. It is okay to list this information rather than write it out.
A. Name
B. Gender
C. Date of birth
D. Current living situation
E. Current place of work
F. Contact information: landline, cell, pager, email, etc.
G. Date(s) of assessment
2) Descriiption of Person System, Family/Household/Primary Social System, & Ecological System—Be
sure to write a narrative for each of the subsections below. An ecomap should supplement the
written narrative.
A. Person System – Present information describing the prospective or identified client. Information
such as height and weight, race and ethnicity, physical appearance, striking or characteristic
features, speech patterns, health, and clothing may be included.
i. Physical appearance—provide enough information so that someone could pick them out of a
waiting room.
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(1) Gender
(2) Race and ethnicity
(3) Do they look their age?
(4) Height and weight
(5) Do they look healthy or sick?
(6) Striking or characteristic features
(7) Clothing
B. Family/Household/Primary Social System—Describe the client’s family, household, or primary
social system.
i. Family of origin
(1) Close or fractured?
(2) Do they express emotions?
ii. Extended family
(1) History of physical illness, substance use, and mental illness (First degree and then
second degree)
(a) Any history of diagnosed psychiatric illness, like anxiety, depression, alcoholism?
(b) Anything not diagnosed, but you highly suspect?
(2) Marriages/divorces, partnerships/break-ups, births, deaths, etc.
C. Ecological System—Describe the ecological system within which the identified client currently
functions. Include an ecomap as an appendix that is referenced in the narrative. Please note the
ecomap should be a visual depiction of this section of the assessment. Identify systems including,
but not limited to the following:
i. School
(1) Are you currently in school? PT? FT?
(2) What are you studying?
(3) How do you like your classes?
(4) How do you get along with your instructors?
(5) How do you get along with your classmates?
ii. Work
(1) Are you currently employed? PT? FT?
(2) What kind of work do you do?
(3) How do you like your job?
(4) How do you get along with your supervisor?
(5) How do you get along with your coworkers?
(6) How do you get along with the customers/clients/etc.?
iii. Health care
(1) Where do you go when you get sick?
(2) Do you have a doctor you see on a regular basis?
(3) When is the last time you saw him/her?
(4) Do you have insurance?
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iv. Recreation
(1) What are your hobbies?
(2) What do you do for fun?
(3) When is the last time you did _______________?
(4) How often do you exercise?
v. Religion/faith/spirituality
(1) Are you spiritual or do you have a religious affiliation?
(2) Is it a big part of your life?
(3) What is your weekly time commitment?
(4) Does it affect what you eat?
vi. Neighborhood
(1) In what neighborhood do you live?
(2) Do you feel safe there?
(3) Do you know your neighbors? Do they know you?
(4) Is there a playground there? Is there a grocery store there? Is public transportation
easily accessible?
vii. Friendship affiliations
(1) Do you have a friend or friends that you can talk to about private issues?
(2) Do you have a significant other? Are you currently in a romantic relationship? For how
long have you been together? Is that person supportive? If no, when was your last
serious relationship?
3) Referral Source and Process; Collateral Information—This section is typically used to summarize the
information concerning the source of the referral (who suggested or required that the identified client
make contact with the worker) and the process by which the referral occurred. Any information
provided by sources other than the identified client or the client system (e.g., family member or a
close friend; agency reports) may be presented here.
4) Presenting Problems and Goals—In this section, describe the client’s view of the problems and goals.
A. Describe the origin and development of the concerns.
B. Summarize the reasons that social work services are sought or required.
C. Record the desired outcome of the social work service as envisioned by the client.
5) Social History—This section includes summary information about the client’s social history as
related to the presenting problem or identified issues. Feel free to incorporate assessment tools
(e.g., culturagrams, life road maps) and theories of development from this course or other
courses. Including information related to stages of individual and/or family development may be
useful.
A. Where was the client born and raised?
B. Developmental progress
C. Interpersonal, familial, and cultural factors
D. Instances of trauma, violence, suicidal attempts, and victimization
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E. Sexual issues, relationships, and development
F. Alcohol and other drug use
G. Physical ability
H. Physical health and medical history
i. Any medical problems (particularly seizures and head injuries)
ii. All current medication names and dosages (daily, as needed greater than 1x per week,
anything over the counter, any herbal medications).
I. Legal issues
J. Educational achievement and concerns
K. Employment history (including military)
L. Financial status and concerns
i. Are they a major stress in your life?
M. Recreation
N. Spirituality and religious life
6) Prior mental health, substance abuse, psychological, or social services
i. Dates and number of sessions of counseling and therapy
ii. Psychiatric medications
iii. Dates of hospitalizations
iv. Dates of suicide attempts
7) Clinical Impression and Missing Information—Assessment is always an ongoing process.
A. Share your clinical impressions (similar to the assessment portion of the SOAP note)
B. Identify additional areas for further assessment. Be sure to explain 1) why the information is
needed, 2) from where it would come, and 3) how you would gather it.
C. Strengths and Resources – Summarize information concerning the strengths and resources
available within the client or situation systems. The kind of resources indicated may range from a
concerned relative or an insurance policy to good physical health.