Comprehensive Client Assessment Paper
Students must address all of the areas described below:
A. Basic Information:
Agency Context: Briefly describe the agency type and setting
Demographics: Provide brief demographics information about the client (gender identity, age, etc)
B. Assessment:
Presenting Problems/Issues and Context: current symptoms and stresses; Stages of Change/motivation; impact of symptoms on functioning; cultural issues.
Client Resources/Strengths: Describe assets, strengths, resources – intrapsychic, interpersonal, in community. Describe coping skills.
C. Client Engagement:
Describe how you engaged the client and developed therapeutic alliance.
D. Multidimensional Narrative Assessment:
Psychological: include DSM 5 narrative diagnostic summary; past psych history and treatment; medications
Biological: Medical issues; health conditions, medications
Developmental History/Application of HBSE (human behavior and social environment): Include Erickson stage; early development; trauma history
Social History: Marital status; children; social network; living situation; socio-economic status; legal issues if any
: Religion or spiritual beliefs; sense of belonging; ethnicity, race, culture; describe contents of Culturagram (required).
E. Intervention:
Describe the theoretical framework you selected and the intervention(s) strategies you selected to work with this client, and why. Describe your process of collaborating on a treatment plan with the client.
F. Evaluation of Practice with Client:
Based on your interactions with this client over this semester, evaluate client’s progress toward achieving his or her goals and objectives. Is there anything you would do differently? Why?
G. Self-Assessment:
Student describes how strengths approach was integrated into client assessment and how own skills have developed in terms of being able to complete a client multidimensional assessment.
