SOWK 441: Generalist Social Work Practice
Case Study Assignment Part 2 – Biopsychosocial Assessment
This part of the assignment is worth up to 60 points and includes the following 6 key
elements. Items highlighted in yellow must be done individually.
1. Confidentiality and Informed Consent Form – 3 points
2. Initial Social Work Assessment – 30 points
3. Genogram – 7 points
4. ADDRESSING Framework (Client) – 5 points
5. ADDRESSING Framework (Social Worker) – 5 points
6. Progress Note – 10 points
Students should follow the four detailed steps below:
1. It is assumed that the group has met and agreed upon an identified client in their chosen
film.
2. The group must identify the (hypothetical) agency where this client and/or the client
system will seek services and the nature of those services based on the assumed needs of
the client at a specific point in time.
a. Details of the identified client’s story from the film will provide context for the
assessment (the client, the client’s family system, the community, the
oader
society impact on the client, presenting problems, client strengths, and client
esources, etc.).
. The agency name and the client’s reason for seeking services / type of services
sought will be included in the Initial Social Work Assessment.
3. The student will individually write an Initial Social Work Assessment based on the
hypothetical interview with the identified client. As part of the Initial Social Work
Assessment, the student will include the following in the assessment document itself:
a. Mental Status Exam (MSE)
• Summary belongs in the “Observation of Client at Assessment” box in the
Initial Social Work Assessment.
• See exemplar on D2L
. Risk Assessment Summary
• Students will choose one of the two risk assessment tools provided by the
instructor.
• Summary belongs in the “Safety Assessment” box in the Initial Social Work
Assessment.
• Actual assessment tool does not need to be completed and turned in. The
summary should include relevant data and your assessment of risk.
• This component can be done as a group.
c. Quantitative Assessment Tool(s)
• Administered (hypothetically) as part of the interview.
• The student will select at least one quantitative assessment tool based on their
understanding of the client’s needs.
• The student will identify their selected assessment tool(s) by name on the first
page of the Initial Social Work Assessment in the space provided.
Students/groups may consult with the instructor for ideas or to discuss
questions.
• The student will summarize the findings of the administered tool in the
“Summary” box of the Initial Social Work Assessment.
• Examples of Quantitative Assessment Tools:
PHQ9 / GAD-7 / PTSD Inventory / MDQ / CAGE-AID / Burns Anxiety
Inventory / etc.
• This component can be done as a group.
4. Students will construct and submit a Genogram for their identified client. This can be
done as a group.
a. The genogram can be uploaded as a separate PDF (or .jpg if you hand-draw and
snap a photo to submit).
. This component can be done as a group.
5. The student will individually write a Progress Note to document the hypothetical
encounter with their client using the DAP (Data, Assessment, Plan) template provided on
D2L. The progress note is the primary means used by social workers to document client
encounters. In this case, we will write the progress note to describe our work when the
initial interview was conducted.
a. Please note: the SOAP (Subjective, Objective, Assessment, Plan) note is another
tool social workers use to document client encounters and progress. We will
practice using the DAP for this course as it is the format you will use in future
social work classes in the program.
. This component is to be completed individually by each student in the group.
sowk-441-part-2-initial-social-work-assessment-with-text-9-kr0u4tvp.docx
[ENTER HYPOTHETICAL AGENCY NAME HERE]
INITIAL SOCIAL WORK ASSESSMENT
Date of Assessment:
Client’s Full Name:
Date of Birth:
Social Worker Name:
Quantifiable Inventories Used:
Risk Assessment Used:
Addendums:
· Confidentiality & Informed Consent Form
· Genogram
· ADDRESSING Framework (Client)
· ADDRESSING Framework (Social Worker)
· Progress Note
Brief Description of Client:
Identify the client system that you will be working with. Briefly describe the client. Include age, sex, gender identity, pronouns, race, ethnicity, socioeconomic status, sexual orientation, marital status, religion/spirituality if any, education, cu
ent employment.
Observation of Client at Assessment:
Describe what you observe (i.e., appearance, mood, speech, affect, thought processing, thought content, sensory perceptions, mental capacities (orientation x 3; intelligence; memory; concentration; self-worth; insight), and attitude toward the interviewer or to the process of being interviewed. Remember, always back things up (i.e., as evidenced by…).
Reason for Refe
al/Client’s Presenting Concern(s)/Client’s Description of Problem:
Who made the refe
al/initial contact with the agency? State the presenting problem in the client’s own words (reason given by the client or the refe
al source).
Client’s Cu
ent Living Situation:
Describe client family and household composition.
Client Goal(s):
Using the client’s own words (as a quotation), describe the kind of change they would like to see, or help/services they would like to access.
Safety Assessment:
Describe risk assessment you have chosen to conduct (data, assessment of risk based on client data).
Physical / Biological Health History
Describe any cu
ent and past medical / health history.
Cu
ent: (e.g., Client reported diagnoses of diabetes and Hepatitis C)
Past: (e.g., Client was diagnosed with asthma as a child but this resolved by approximately 12 years of age; Client was treated for pediatric cancer at age 3. The cancer has never recu
ed.)
Mental Health History (Including Hospitalizations / Treatment):
Describe any cu
ent and past treatment, diagnoses, and hospitalizations.
Cu
ent: (e.g., Client reported the following mental health diagnoses: Major Depressive Disorder, PTSD, etc.).
Past: (e.g., Client reported having been diagnosed with depression as an early adolescent. She was hospitalized while in college after disclosing to her roommate that she was experiencing suicidal ideation. She has not been hospitalized since.)
Cu
ent Medications:
Describe cu
ent medication (e.g., Client X reported taking a daily multivitamin and serotonin for sleep before bedtime.)
Substance Use Disorder History (Including Hospitalizations / Treatment):
Describe any cu
ent and past treatment, diagnoses, and hospitalizations. Include information about substances used.
Cu
ent: (e.g., Client is cu
ently in recovery. She reported having abstained from using illicit drugs and alcohol for the last 3 years and 2 months. She does use caffeine (3xdaily)).
Past: (e.g., Client has a history of illicit drug use and substance use disorder including methamphetamine, heroin, and marijuana. Client reported that she abused alcohol if she had a hard time obtaining her other drug of choice in the moment. Client has completed both inpatient and outpatient chemical dependency treatment).
Family Health history:
Describe any family health history (diabetes, heart disease, genetic factors, disability, etc.).
Family Mental Health / Substance Use Disorder History:
Describe any family mental health and / or substance use disorder history. If there is no history of familial substance use disorder or addiction, state this (e.g., Client reports no known history of substance use disorders in his / her family of origin).
Developmental History (including trauma history):
Describe where the client was raised and by whom (e.g., Client X was raised by her biological parents and has two older
others). Describe her family system (siblings, step-siblings, etc.). Describe any trauma or complications related to the client’s birth (e.g., Client reported that her birth was considered overdue but without complications). Client will describe his/her own childhood and the client’s words should be used, whenever possible (e.g., Client reported meeting developmental milestones as expected). If client has trauma history, it should be included here (e.g., Client reports a history of sexual and physical abuse as a young child in her family of origin. Client’s family was involved with the child welfare system numerous times during her childhood. Client and her siblings were in out-of-home placement on two separate occasions and/or Client reported a history of domestic violence in her family of origin and in her most recent ma
iage which has since ended).
Significant Personal Relationships (social, family, interpersonal):
Describe client’s most significant relationships. This should include relationship status, relationships with family including any children/parents, and relationships with close friends. This helps us to have a complete picture of the client’s social support network (e.g., Client X is cu
ently in a relationship with her boyfriend. They have been together for approximately 11 years. Client X reported having many friends and has two close friends whom she sees regularly. She has close relationships with her two adult children and with her mother and step-father. She reported not having a relationship with her
other and his family).
Client Strengths and Resources:
Describe client’s strengths using client’s words (e.g., Client x articulated her strengths as being strong, funny, loving, and hard-working. She has a supportive family, a stable job that she enjoys, and a nice home).
Cultural Influences:
Describe the client’s cultural identity as evidenced by the completed ADDRESSING framework.
Additional history of head injury, operations, illness, etc.:
Describe any additional history of head injury (including history of concussions due to accidents, athletics, etc.) and any history of surgical operations, illnesses, etc. Sometimes this is captured in the biological / physical part of this assessment, but we like to ask these specific questions about head injury given the real implications of head injury and subsequent personality changes and behavioral / mental health related symptoms.
Legal History:
Describe the client’s self-reported legal history. If the client is working with you under a judge’s order / court mandated services, indicate this here. It would also be indicated under “reason for refe
al” if the client suggests that the reason they are seeking services is because the court said they were required to do so.
Areas of Functional Impairment or Significant Concern (check all that apply):
Vocational functioning
Substance Use
Food Insecurity
Interpersonal Functioning
Medical Health
Housing
Educational Functioning
Dental Health
Legal
Self-Care