Instructions
Integrated Assessment For this assignment be sure to protect client confidentiality (change client name or other identifying information). Cite the sources of information used in your assessment (i.e. interview and observation of client, existing case record, family or social network, etc.). Part 1: Bio-Psycho-Social-Spiritual Assessment (5-7 pages) Use this to conduct a strengths-based, bio-psycho-social-spiritual assessment. Basic information: Agency/context where the client is being assessed: Presenting problem/reason for seeking care: Gender: Age: Ethnic/cultural identity: Socioeconomic status: Employment/education: Other relevant information: Cultural context (Use Cultural Formulation Interview) Cultural values, traditions: Spiritual or religious beliefs: Social justice issues: Client history Behavioral Mental health history: Medical History including medications: Substance use history: Family medical and psychiatric history: Brief developmental and social history: Legal/violence history: Abuse or trauma history: Diagnosis and functioning: Mental status exam brief summary: DSM-5 diagnosis: Justification of diagnosis: ROPES (see Graybeal, 2001) Clients’ resources: Clients’ options: Clients’ possibilities: Clients’ exceptions: Clients’ solutions: Part 2: Goals and Needs – 2-3 pages How well is the client currently meeting their needs? What are the specific objectives, actions and outcomes the client identifies, including: Immediate goals and needs Mid-range goals and needs Long-term goals and needs How can the client be supported in further developing their strengths? Self-assessment What are some similarities and differences between yourself and the client? What have you learned about your own biases and tendencies (either positive or negative) through this process? How will you attend to your own biases and maintain boundaries while working with this client?
**ITS FOR MY VETERAS CLIENT IN HAWAII **