Presenting problem/concern – A brief account of the stated reason for seeking services, including who sees the situation as concerning and why they see it as concerning. This should include referral source (if available), voluntary or involuntary status, number, length, and nature of contacts, and sources of information including the client’s statement as to why she or he is seeking help at this time.
Background information – Provide a brief demographic profile including the client’s cultural background. Give a brief history of the presenting problem, psychiatric, drug or alcohol use, legal issues, family, social and medical, current living and financial situation, etc.
Assessment – this consists of three subsections.
Assessment Process: Briefly describe how you would have established rapport with the client. What skills do you think will be successful in developing a working alliance with the client? This includes describing “use of self” in establishing a therapeutic alliance. Discuss factors related to your and your client’s cultural background (e.g., similarities, differences, etc.). Personal and environmental strengths (resources and skills) as well as challenges (deficits) for the client. These include personal appearance, health and hygiene, response to life cycle changes, use of alcohol and other drugs, intellectual functioning, cognitive flexibility, functional/dysfunctional beliefs/behavior patterns, judgment/self-control, emotional range, appropriateness of emotional display, cultural identification, acculturation, motivation, etc.
– Evaluate the client’s environment, addressing the following areas: primary support group (e.g., family, relationships with parents, siblings, partner, children, stability of relationships, etc.), social environment (e.g., friends, availability of and participation in recreation, availability of and involvement in social/cultural/religious organizations), education (e.g., level of education, adequacy of educational environment, relationship with teachers/classmates, opportunities for self-development/education), occupation (e.g., work opportunities, employment status, safety and stability of work, work schedule, satisfaction with job, relationship with employer/coworkers), housing and neighborhood (e.g., safety adequacy of space, stability of living arrangements, security/police/fire protection), economic issues (e.g., adequacy of financial resources, sources of financial support, financial obligations), health/social service issues (e.g., availability of services, relationship with service providers, adequacy of health insurance), legal system (e.g., legal actions, arrest, crime victim), other issues (e.g., adequate transportation).
Goals and objectives – briefly summarize three concerns/problems selected for change and goals for these concerns. These goals and objectives will be developed by you, based on what you believe the client would express as a priority. Define concerns in an ecological context and operationalize them so a concrete goal can be established.
Preliminary Intervention Plan – discuss future directions for work with the client. This should include a discussion of the interventions to be used to move the selected concerns from their current status to the goals and objectives. Concerns and goals – identify and specify three (3) central problems/concerns for this client in order of priority. Treatment plan – propose a course of treatment including number of sessions, setting, treatment modality, etc. Identify who you would target for the intervention? How would your intervention be culturally competent?