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TRANSCRIPT
Chapter 8Chapter 8Assessment
AssessmentGoal
Address historical informationUncover richer elements & how they relate to
each otherMore than just behavior
Assessment process Time frameOverview to clientGo with client flow
Documentation
AssessmentGoal
Address historical informationUncover richer elements & how they relate to
each otherMore than just behavior
Assessment process Time frameOverview to clientGo with client flow
Documentation
AssessmentDimension 1:
Presenting Issue/sWhat brings the
person? Self/family Referral
Understanding their perspective View on issue Problem? Priorities Initial motivation
Dimension 2: Treatment history
Background information on presenting issue
Prior history and experience
Current reflections What helped/didn’t help
AssessmentDimension 3: Substance use history
Now & in the past; build on screening Frequency Amount Age at first use Last used Administration Overdose, etc Patterns (now & in the past) Periods of abstinence Family history
Substance First
UseLast Use
Pattern
Route of admin
AssessmentDimension 4: Medical history
Known conditionsExams/providers/hospitalizationsUnmet medical needs/risksMedicationFamily history
Dimension 5: Basic needsBeing met?ADLsReferrals
AssessmentDimension 6: Psychological functioning
Known MH conditionsTraumaHospitalizationsHistory, pattern with/without SARisks
SI/attempts History
Family history
AssessmentDimension 7: Family history & structure
“Who is family”/basic statsFamily relationships/dynamics/estrangementsView on family
Dimension 8: Social/cultural contextsEnvironment/living situationCommunity resources/outletsStressors
Financial Housing
AssessmentDimension 8: Sub-dimensions
Cultural/spiritual values, beliefs & strengthsSESVocational historyEducational historySocial-relationalLegal history
Arrests Incarcerations Current status
AssessmentDimension 9: Motivation
Values & strengthsHopes & dreamsClient readiness/stage of change
Dimension 10: DiagnosisDiagnoses (SUD; MH; Medical)Psychosocial/environmental stressorsMSE & clinical impressionsRecommendations/planAssessment procedures
Attend to cultural factors throughout entire assessment process