1) Introduction/Description of the Client:
· Provide a complete description of the client you are focusing on including their age, gender, race & ethnicity, physical characteristics, socioeconomic status, educational background, and other important details that describe the client’s social location & social memberships
· Clearly state why/how the client has come to your agency/organization (did they come to the agency on their own to request help? Were they referred by another organization?)
· Clearly state the agency’s general purpose in working with this client (what the agency is intending to do to help)
2) Client’s Background and History:
· Summarize what you know about your client’s history, describe what you know about the client’s life and background prior to their meeting you and coming in contact with your field agency. Include important biological, psychological, and social factors from their past that have impacted their lives.
3) Bio-Psycho-Social-Cultural-Spiritual Assessment of the Client: Provide a complete description of your client’s presenting problems, challenges, needs and risk factors as well as their strengths, supports, and protective factors, integrating the following:
· Biological: What is happening with your client in terms of their biological and physical health and well-being? Are they experiencing any significant biological stages or changes (things like puberty, pregnancy, recovery from addiction)? What strengths do they have in this area and what challenges do they have in this area? Be sure to include any health problems or physical diagnoses they have.
· Psychological: What is happening with your client in terms of their psychological and emotional health and well-being? What strengths do they have in this area and what challenges do they have in this area? Be sure to include any mental health diagnoses they have.
· Social: What is happening with your client in terms of their social and environmental health and well-being? Are they going through any significant social changes or stages (grief, changing schools, problems with friends, relationship challenges/disruptions, leaving home, community unrest, etc.). What strengths and supports do they have in this area and what challenges or obstacles do they have in this area? Be sure to describe the client’s family system/context, important relationships with family members and significant others, friends, community members/groups.
· Cultural/Spiritual: What information do you know about the client’s socio-cultural/spiritual context? What strengths and supports do they have in this area and what challenges or obstacles do they have in this area? Describe ways in which the client’s cultural identity, history, and affiliations are protective factors, as well as any socio-cultural risk factors that exist (including bias, discrimination, poverty, etc.)
