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Psychosocial Assessment how to complete an assessment Appendix A An Outline for a Biopsychosocial Assessment and Intervention Plan I. Referral How and why

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Psychosocial Assessment how to complete an assessment Appendix A
An Outline for a Biopsychosocial
Assessment and Intervention Plan

I. Referral
How and why did the client(s) get to the agency? Is the client self-referred? Is the
client voluntary or involuntary?

II. Description of Client
Who is the client? Briefly document relevant identifying information including:
Age, gender identity, marital/partner status, race, ethnicity, sexual orientation,
religion, social class, income source(s), disabilities, level of education, prominent
health issues, medications, substance use, and legal issues.

III. Presenting Issues and Concerns
What are the client’s complaints? What are the larger presenting issues? How does
the client view these concerns/issues? How do other people (family, friends,
agency, work, school, courts, physicians, religious community, you, etc.) view the
concerns/issues?

When did these concerns/issues begin? Is there an identifiable precipitant? Why
is the client coming in now?

How has the client dealt with these or similar concern/issues in the past? What
would the client most want help with?

IV. Assessment of Relevant Contextual, Historical, and Intrapersonal Factors

a. Current context What are the family, social community, work, and other
issues relevant to an understanding of the client and the problem? (An eco-
map and/or a family genogram, identifying family, and environmental
resources may help clarify these intertwining issues.)

• Are the client’s basic needs met? (Housing, food, clothing, utilities,
emergency, or situational needs such as diaper services or money for
medicine or care of pets while inpatient?) What are the clients’ strengths
in meeting basic needs? Are these needs met in a culturally appropriate/
sensitive manner?

J. W. Drisko and M. D. Grady, Evidence-Based Practice in Clinical Social Work,
Essential Clinical Social Work Series, DOI: 10.1007/978-1-4614-3470-2,
� Springer Science+Business Media New York 2012

259

• What are the clients’ income sources? Are they stable? Can they be
improved? What are the clients’ strengths in meeting basic needs? Is
this income obtained in a culturally appropriate/sensitive manner?

• Are there language issues for the client in the services and communities
to which they relate? In meeting basic needs? In the school or
workplace? Are interpreters available? Is language training accessible if
sought? What strengths and challenges does language pose for the
clients?

• If the client has disability issues, how adapted/accessible are home,
neighborhood, workplace, schools, stores, and professionals? How are
communication needs met? How are transportation needs met? Does the
client have access to needed equipment for safety and for daily living
skills? Does the client have training to use such equipment/devices?
How is this disability understood in the clients’ cultural context? What
strengths are evident related to this disability?

• Are the client’s medical and dental needs met? (This includes routine
checkups, assessment of illnesses, emergency care, immunizations,
dental care, rehabilitation services, access to medications or rehabili-
tation equipment, access to nursing help, and access to long-term care,
etc,) Are the services culturally appropriate? Accessible?

• Are the client’s safety needs met? (Domestic violence, abuse or neglect
of children or elders, violence in housing, neighborhood, and specific
threats?) Is the client’s physical environment safe? (Free of fire hazards,
with accessible fire escapes, no lead paint, etc.?)

• Does the client pose a hazard to the safety of self or others; specifically
is there suicide risk or lethality risk? Fire setting risk? (If any of these
apply, a specific detailed evaluation and documentation is also
required.)

• Is domestic, partner, or marital violence an issue? If so, is a safety plan
in place?

• Are there child protective, disability, or elder protective issues for the
clients? If so, is there a service plan? What services are involved? What
services/needs are ignored?

• Are there legal issues for the clients? Any court involvement, restraints,
obligations? Are there obligatory services, costs, or settlements unpaid?

• What is the client’s immigration status? Could this be a source of being
unsafe or exploited?

• What is the client’s religion or spiritual beliefs? What level of
involvement do they have with their religion or spiritual organization,
its practices, and its community? Does the client have other connections
to spirituality? How do these (religion and/or spirituality) shape the
meaning of the client’s life?

• What are the client’s recreational interests? How and where are these
met? Are there barriers to recreational activities?

• What are the client’s key social supports? Are they accessible?

260 Appendix A: An Outline for a Biopsychosocial Assessment and Intervention Plan

• Are there important social policy or social structural aspects to the
client’s situation and problem? Has (or could) the client joined with
others to address these issues? How?

b. Historical influences Summarize, as relevant, past material about

• Client’s childhood, including developmental history.
• Relationships with family of origin.
• School and work history.
• Previous experiences with social, medical or psychological services.
• Intimate relationships.

c. Coping strengths and weaknesses

• What are the client’s key self-reported strengths? Are there other
strengths you observe or can infer?

• How does the client process information? Protect themselves from
anxiety and stress? Who do they turn to for support and nurturance?

• How does the client characteristically interact with others? Are these
strategies successful in meeting the client’s needs? Are they routinely
problematic? Can the client show flexibility in style of interaction?

• How do these strengths, challenges, and abilities fit with the client’s
social and institutional resources? What resources or obstacles facilitate
or inhibit the client’s mastering current issues/concerns?

• What role do current life cycle tasks play in relation to the concerns and
issues that have been identified?

V. Formulation
Develop a brief, clear, biopsychosocial summary of the above material that
integrates relevant developmental, theoretical (i.e., psychodynamic, cognitive-
behavioral, P–I–E, family systems, or risk and resiliency), family, and
sociocultural issues. How would you state the client’s dilemma in easily
understood words that capture the key concerns and strengths?

VI. Plan for Intervention
Drawing upon the formulation, describe your plan for intervention. Identify your
goals, separating immediate from long term. What would be the core elements of a
treatment contract with this client? Are there elements that might be
uncomfortable or unacceptable to the client?

VII. The Best Research Evidence
Given the proposed plan for intervention, what does the research evidence indicate
are the best likely effective treatments or services to discuss with the client? Are
the treatments realistically available and can they be funded? Are these treatments
likely to be accepted by the client?

VIII. Values and Ethics: The Worker’s own Values and Experience
What are the value, ethical, diversity, personal reactions, and other challenging
issues that surface in this case? Will these alter what you can offer and provide?

Appendix A: An Outline for a Biopsychosocial Assessment and Intervention Plan 261

IX. Organizational Issues
How will your agency mission and practices shape further service delivery? What
organizational factors aid successful services for this case? What factors are
barriers or impede services for this case?

X. Social Change Goals
What social change goals can be part of, or related to, your work with the client?
What resources might you mention to the client as ways to promote the changes
they wish to help make? What resources might you help connect the client with to
promote these changes? How might you work to promote social changes related to
this client and case?

� 1997, 2005 by James Drisko and Carolyn DuBois—used with permission from
the authors

262 Appendix A: An Outline for a Biopsychosocial Assessment and Intervention Plan

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