• Include history of trauma, losses.
• History of medical problems, substance use, legal issues.
• Relevant early family or developmental events.
Observational Assessment (What You Observe):
• Description of the client’s appearance and behavior during the assessment period. (Ex: observed behavior, level of cooperation. Ability to relate to interviewer. Any symptoms or unusual behavior during the initial assessment period.
• A formal mental status may be used in some agencies. (Describes mood and affect, level of coherent thinking or speech, delusional thinking, hallucinations, cognitive functioning, suicidal or homicidal thinking.)
Formulation – Your Impressions: (This will provide support for your intervention plan).
• Start with restating key identifying information, presenting problem and referral source.
• Present your understanding of the problem, the causes, and your analysis of the most important factors affecting the problem.
• Your impressions of the client’s ability to use help, move toward change – what are the client’s strengths, protective factors or risk factors affecting capacity for change.
Treatment or Intervention Plan:
• Describe in a brief narrative format your intervention
Yep, you repeat all over again in the second process. Providing social services requires lots of paper work and accuracy. One of the main responsibilities usually involves some type of treatment planning and/or service plan. These plans usually include a social history/assessment (you already have it completed), goals, objectives and intervention (specifics on how the clinician will help).
The assessment usually includes basic demographic (name, race, address, age etc.). The assessment also includes some of the main issues the client is facing, prior history of treatment, legal concerns, drug history and anything else you can think of that is important for treatment purposes.
Goals are something that the client is going to work on for life i.e. the client usually does not accomplish their goal. Instead, they constantly work toward achieving it.
As you can see, this is very long-term and a person usually does not say “I have enough self-esteem…I am going to stop working on that”
Also, as you see, I started the goal off positively. So, you want to use terms such as: “continue, maintain, enhance etc.
These may make more sense to you. These are measurable and are related to the goal. These are measurable because they should be very specific.
The client will attend counseling 3x weekly
The client will attend drug treatment for at least 30 days
You see how objectives are measurable?
Simply, what the clinician does to help the client achieve their objectives and work towards goals.
The clinician will provide transportation
The clinician will provide counseling 3 x weekly
The clinician will provide weekly groups
Assignment: Complete a treatment plan using information from your completed psychosocial history on “Beth.” You can find your own template on line, but must include the following:
1. Write at least 4 goals
2. Write at least 4 objectives
3. Write at least 4 interventions
4. 3 Strengths
5. Rationale or brief discussion of your chosen treatment approach and interventions
6. 3 “real” agencies to which you would refer Beth locally.