CUNY Lehman College Bio Psycho-Social Assessment Project
Utilize the case material presented in Episode 6Reservation Dogs(2022) orMoonlight (2016).
Develop a comprehensive bio-psycho-social assessment that demonstrates your ability to integrate case information with relevant theory to guide your formulation of the critical case issues.
Refer to Hepworth Chapter 9 (pages 243-245) for an example and Saleebey Chapter 10 for Strengths in Assessment
1. Select one character to be your client and use the bio-psycho-social assessment outline below as your format for structuring and developing the content for your assessment. (Reservation Dogs: Willie Jack or Leon; Moonlight: Chiron or Paula)
2. Make at least two references (APA style) to theories that guide your understanding of the case dynamics. Attached to the outline is a guide to assist you in developing your assessment.
3. Follow the format, using the corresponding headings and provide information for all relevant topics. (Note: Some information may not pertain to your “client” or your client may not know the information. For example, your 5-year-old client will have no history of military service or your client may not know about her family’s mental health history. Whatever the situation, indicate this by noting whether the information is non-applicable or not known).
4. Information should be based on information we know from the client (character), collateral contacts (what we know from other characters), and on your observations. *You will be making up some elements that in a real case you wouldn’t need to (such as referral source, reason for referral). Keep that information realistic and in line with what we do know.
I.Identifying Information
Name
Age, Sex, Gender identity
Ethnic background/identification (include acculturation issues if applicable)
Marital/Relationship Status
Appearance, orientation, presentation (affect, dress, gestures, tone of voice)
Current employment/educational status
Household composition and circumstances (current living situation)
II.Presenting Problem / Reason for Referral
1. Referral source (if not known, you can create based on what the film provides)
2. Who made the initial contact
as reported by the client
4. Onset of the problem, duration, severity
III. Client Description/History
2.Family Composition and History (include family composition, family of origin history/dynamics, intergenerational themes, cultural factors)
3.Educational and Occupational History
4.Religious (Spiritual) Development
5.Social Relationships
6.Dating/Marital/Sexual Relations
8.Mental Health History (include known diagnoses, treatment history, medications and outcomes)
9.Alcohol/drug use/abuse (include patterns of use/impairments, known diagnoses/treatment and outcomes)
10.Military History (include service branch and combat experience)
11.Legal History (include past and current history with the legal system)
12.Other Agency Involvement (include past/present involvement/experience with social service agencies)
IV. Current Functioning
Current Stressors
Relationships: family, friends, co-workers
Role Functioning
Coping and Adaptive skills (include use of leisure time activities)
Strengths – social/political, personal/interpersonal
Barriers, obstacles and risks affecting the problem – environmental, interpersonal, intrapersonal, social/political
VI. Plan
Guide to Completing Bio-psycho-social Assessment
I. Identifying Information
This section includes such information as age, gender, race, religion, marital status, occupation, living situation, etc. Information should be factual, based on information from the client, collateral contacts, and case records.
It should contain objective information observed/obtained by the worker including:
othe client’s physical appearance (dress, grooming, striking features)
ocommunication styles and abilities or deficits
othought processes (memory, intelligence, clarity of thought, mental status, etc)
oexpressive overt behaviors (mannerisms, speech patterns)
oreports from professionals or family (medical, psychological, legal)
oMental status exam (if appropriate)
II. Presenting Problem/Reason for referral
This section identifies the referral source and gives a summary of the reason for the referral according to the referral source.
oIncludes the client’s description of the problem or services needed, the duration of the problem and its consequences for the client
oPast intervention efforts by an agency or the individual and/or family related to the presenting problem should also be summarized.
Identify areas that have been effected by the presenting problem:
family
physical and economic environment
educational/occupational issues
physical health
III. Client Description/History
If relevant, identify non- western expectations and practices for child rearing and development for clients from diverse backgrounds.
Stressful experiences client has encountered throughout his/her life; ability to cope with these stressors; how they have solved the “tasks” of various developmental levels.
Family Composition and History:Include family composition, birth order, where and with whom reared; relationship with parents or guardian; relationships with siblings; abuse or other trauma; significant family events (births, deaths, divorce, separations, moves, etc.) and their effect on the client(s); interacting roles within the family (e.g. who makes the decisions, handles the money, disciplines the children, does the marketing); and typical family issues (e.g., disagreements, disappointments).If not noted previously, immigration/acculturation history could be included here as appropriate.
Educational and Occupational History: Level of education attained; school performance; learning challenges, difficulties; areas of achievement; peer relationships; skills and training; type of employment; employment history; adequacy of wage earning ability; quality of work performance; relationship with authority figures and coworkers.
Belief systems, Religion and Spirituality: Importance of belief systems, religion and spirituality in upbringing; affinity for religious or spiritual thought or activity; involvement in belief-based, religious and spiritual activities; positive or negative experiences.
Social Relationships: Size and quality of social network; ability to sustain friendships; pertinent social role losses or gains; social role performance within the client’s cultural context. Patterns of familial and social relationships historically.
Dating/Marital/Sexual: Type and quality of relationships; relevant sexual history
Relationships: significant losses; traumas; conflicts in intimate relationships; ways of dealing with losses or conflicts. Currently, where do problems exist and where does the client manage successfully?
Environmental Conditions: Urban or rural; Indigenous or new to the neighborhood where they live; economic and class structure of the neighborhood in relation to that of the client; description of the home.
Medical History:Includes major illnesses, diagnoses, current medications, hospitalizations, accidents, disabilities for the client.It should also include significant family history.
Mental Health History:This includes known diagnoses, illnesses, treatments, outcomes and current medications for the client as well as the family.
Military History: Include whether the client served in the armed forces, saw combat and overall experience.
Legal: Juvenile or adult contact with legal authorities; type of problem(s); jail or
Problem(s) chosen for intervention
Goals and objectives taken to achieve goals.
Outlining of client role and responsibilities in achieving goals and objectives
Include referrals to other agencies and services; recommendations for involvement of other resources.
Anticipated time-frame (e.g., frequency of meetings, duration of the intervention)
Factors that may affect goal achievement (client motivation; willingness to take responsibility for change; personal and cultural resources; and/or personal abilities or limitations; agency
prison sentence; effects of rehabilitation.
Other Agency Involvement:This includes the client or his/her family’s past and present experience and involvement with social service agencies and the outcome of the involvement.
IV. Current Functioning
This section describes the client’s functioning in their multiple roles (as partner, parent, friend, co-worker, employee, sibling, son/daughter, etc).
V. Formulation
As appropriate, the worker includes impressions of:
Social emotional functioning–ability to express feelings, ability to form relationships,
predominant mood or emotional pattern (e.g., optimism, pessimism, anxiety,
temperament, characteristic traits, overall role performance and social competence,
Psychological factors–reality testing, impulse control, judgment, insight, memory or
notable problems. If applicable, include a formal diagnosis (e.g., DSM IV-TR, Global
Environmental issues and constraints or supports from the family, agency, community
improved functioning (family, friends, church, school, work, clubs, groups, politics,
leisure time activities).
family, agency, community that affect the situation and its resolution.
Conclude this section with a statement about the client’s motivation, sense of self-efficacy, belief in capacity to change.
This section is based on your formulation: your integration of the factors in the multiple streams of information you have gathered. It should map out a realistic intervention strategy to address the presenting problem that builds on the strengths of the client, their motivation for and belief in the possibility of change and is aimed at empowering the client to be their own best problem-solving resource. Your intervention plan should include:
