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

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 Use Last 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: DiagnosisCurrent: Axis I-V; soon to changeMSE & clinical impressionsRecommendations/planAssessment procedures

AssessmentDimension 9: Motivation

Values & strengthsHopes & dreamsClient readiness/stage of change

Dimension 10: DiagnosisCurrent: Axis I-V; soon to changeMSE & clinical impressionsRecommendations/planAssessment procedures