How and why did the client(s) get to the agency? Is the client self-referred? Is the
client voluntary or involuntary?
II. Description of Client
Who is the client? Briefly document relevant identifying information including:
Age, gender identity, marital/partner status, race, ethnicity, sexual orientation,
religion, social class, income source(s), disabilities, level of education, prominent
health issues, medications, substance use, and legal issues.
III. Presenting Issues and Concerns
What are the client’s complaints? What are the larger presenting issues? How does
the client view these concerns/issues? How do other people (family, friends,
agency, work, school, courts, physicians, religious community, you, etc.) view the
concerns/issues?
When did these concerns/issues begin? Is there an identifiable precipitant? Why
is the client coming in now?
How has the client dealt with these or similar concern/issues in the past? What
would the client most want help with?
IV. Assessment of Relevant Contextual, Historical, and Intrapersonal Factors
a. Current context What are the family, social community, work, and other
issues relevant to an understanding of the client and the problem? (An ecomap and/or a family genogram, identifying family, and environmental
resources may help clarify these intertwining issues.)
• Are the client’s basic needs met? (Housing, food, clothing, utilities,
emergency, or situational needs such as diaper services or money for
medicine or care of pets while inpatient?) What are the clients’ strengths
in meeting basic needs? Are these needs met in a culturally appropriate/
sensitive manner?
J. W. Drisko and M. D. Grady, Evidence-Based Practice in Clinical Social Work,
Essential Clinical Social Work Series, DOI: 10.1007/978-1-4614-3470-2,
Springer Science+Business Media New York 2012
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• What are the clients’ income sources? Are they stable? Can they be
improved? What are the clients’ strengths in meeting basic needs? Is
this income obtained in a culturally appropriate/sensitive manner?
• Are there language issues for the client in the services and communities
to which they relate? In meeting basic needs? In the school or
workplace? Are interpreters available? Is language training accessible if
sought? What strengths and challenges does language pose for the
clients?
• If the client has disability issues, how adapted/accessible are home,
neighborhood, workplace, schools, stores, and professionals? How are
communication needs met? How are transportation needs met? Does the
client have access to needed equipment for safety and for daily living
skills? Does the client have training to use such equipment/devices?
How is this disability understood in the clients’ cultural context? What
strengths are evident related to this disability?
• Are the client’s medical and dental needs met? (This includes routine
checkups, assessment of illnesses, emergency care, immunizations,
dental care, rehabilitation services, access to medications or rehabilitation equipment, access to nursing help, and access to long-term care,
etc,) Are the services culturally appropriate? Accessible?
Sample Solution