go to “Documentation of Care, Treatment, or Services in Behavioral Health Care: Your Go-To Guide” and click Download Sample Pages. Download the sample pages and read the information about documentation.
repare a detailed biopsychosocialspiritual assessment report for a mock client you worked with in one of your synchronous sessions. In your report, include all information outlined in the Biopsychosocialspiritual Assessment document.
At the end of the documentation, sign the report as you, the learner social worker (including your credentials) and date it.
Report format: The report should be single-spaced with a blank space between paragraphs and/or sections. Headings should be used and bolded in order to make the sections in the report easy to read and easy to find. Done well, the report is probably one of the more difficult documents to write. What is important is that the assessment provides sufficient information so that any other professional could read the report and have a clear understanding of the major aspects, problems, and strengths of the client.
Summarize a Related Scholarly Article
In addition to your assessment report, search the Capella library databases for one scholarly (peer-reviewed) journal article related to the client’s problem or the type of intervention one would consider using with the client. It is important your documentation is in line with the literature, and there is clear rationale as to why you are doing what you are doing.
Using the critical thought process, write one paragraph about the article and why it was chosen. Attach the article to the report.
Using scholarly articles in our practice with clients is one way to link research to practic
The biopsychosocialspiritual assessment and intervention plan are to be written as though they
will be presented to a court or interdisciplinary team. That is, they are to be written in a
professional format, rather than as a course paper. This format will be discussed in the
Biopsychosocialspiritual Assessment Format
I. Identifying Information
A. Who was the provider in the session (your name and credentials)
B. Location of session, who was present (did the client come alone, with a family,
friend, or partner), date, and length of session
C. Confidentiality and Informed consent (written and verbal)
D. Demographic information: age, date of birth, sex, ethnic group, current employment,
marital status, physical environment/housing: nature of living circumstances
(apartment, group home or other shared living arrangement (who lives in the home),
E. Referral information: referral source (self or other), reason for referral. Other
professionals or indigenous helpers currently involved.
F. Data sources used in writing this assessment: interviews with others involved (list
dates and persons), tests performed, other data used.
II. Presenting Problem
A. Description of the problem, and situation for which help is sought as presented by the
client. Use the client’s words. What precipitated the current difficulty? What feelings
and thoughts have been aroused? How has the client coped so far?
B. Who else is involved in the problem? How are they involved? How do they view the
problem? How have they reacted? How have they contributed to the problem or
C. Past experiences related to current difficulty. Has something like this ever happened
before? If so, how was it handled then? What were the consequences?
III. Background History
A. Developmental history: from early life to present (if obtainable)
B. Family background: description of family of origin and current family. Extent of
support. Family perspective on client and client’s perspective on family. Family
communication patterns. Family’s influence on client and intergenerational factors.
C. Intimate relationship history
D. Educational and/or vocational training
E. Employment history
F. Military history (if applicable)
G. Use and abuse of alcohol or drugs, self and family
Treatment and Outcome of treatment (i.e. out patient or in-patient)
H. Medical history: birth information, illnesses, accidents, surgery, allergies, disabilities,
health problems in family, nutrition, exercise, sleep
I. Mental Health history: previous mental health problems and treatment,
hospitalizations, outcome of treatment, family mental health issues.
J. Personal Events: deaths of significant others, serious losses or traumas, significant
life achievements (Note: these events can be positive or challenging in nature)
K. Cultural background: race/ethnicity, primary language/other languages spoken,
significance of cultural identity, cultural strengths, experiences of discrimination or
oppression, migration experience and impact of migration on individual and family
L. Spirituality: denomination, church membership, extent of involvement, religion,
perspective, special observances
A. Psychosocial / Developmental History:
1. Examples: Family of origin history
2. Education/vocational background
3. Relationship history/ marital status
4. Trauma and Abuse history (has client ever been sexually, emotionally, or
physically abused? To their knowledge, have they ever sexually, physically,
or emotionally abused another person?)
5. Legal History (current or past legal concerns)
6. Relevant Religious/spiritual/ cultural factors
B. Current Substance Use:
4. OTC Supplements:
1. For each of the above:
a. First time they used? How much for each? Last time they used
and how much? Difficulty stopping or cutting back? Impacting
work, family, or other obligations? Others asking client to cut
back? Medical provider asking them to cut back? Cravings,
withdrawal history etc.
C. Military History
1. Disciplinary issues
2. Characterization of discharge and reason
3. Deployment History (combat zone or other, location, etc)
4. Blast exposure/ combat related TBI
5. Combat exposure/ deployment related PTSD
1. What is the key issue or problem from the client’s perspective? From the
2. How effectively is the client functioning?
3. What factors, including thoughts, behaviors, personality issues,
environmental circumstances, stressors, vulnerabilities, and needs seem to
be contributing to the problem(s)? Please use systems theory with the
ecological perspective as a framework when identifying these factors.
4. Identify the strengths, sources of meaning, coping ability, and resources that
can be mobilized to help the client.
5. Assess client’s motivation and potential to benefit from intervention
E. Pain Assessment (location of pain in the body and intensity of pain, measurable on a
scale of 0 to 10 with 0 being no pain and 10 being extreme unbearable pain)
F. Suicidal and homicidal assessment (assess for imminent risk: plan, intention, means,
1. Related Safety plans
2. All assessments should document that you reviewed the nearest resources
(ER or hospital) in case of a change in mental health status or emergency
even if a client is not suicidal, homicidal or experiencing perceptual
G. Medical Concerns and conditions
1. Diagnosis of medical concerns
2. Medications, dose, schedule, reason for medication
3. Primary Care Provider name and contact information
4. Any specialist contact information and name
1. Documentation of other providers involved allows you to pursue
consent if needed and allows you to make referrals for any medical
care concerns as needed and helps ensure care is comprehensive
5. Any physical, intellectual, or mental health disabilities
H. Psychiatric history
1. Past hospitalization
2. Family history or mental illness or substance abuse
3. Past mental health treatment
I. Protective Factors (Examples below and will be different for each client)
1. Willing to engage in treatment
2. Contracts for safety
3. Has safety plan/knows how to access resources
4. Feels attached to family/friends
J. Protective Factor Statement if Applicable: Client is willing to engage in treatment,
contracts for safety and has safety plan/knows how to access resources, feels attached
to family/friends, denies current plan or intent. The patient stated in the case his
mental status should change he would contact his command.
K. Full Mental Status Examination (Use the format below)
1. Orientation: Alert and Oriented to person place and time?
2. Grooming: Adequate/Appropriate, Inadequate/Inappropriate and how
3. Behavior: Cooperative, easy to engage appropriately interactive, good eye
contact or other?
4. Speech: Normal rate, rhythm, prosody and tone or other?
5. Psychomotor: No Abnormalities or psychomotor agitation or retardation
6. Mood: Euthymic or other?
7. Affect: Congruent or other?
8. Thought process: Linear, logical and goal directed or other?
9. Thought content: Appropriate, Denied A/VH, no evidence of delusions or
psychosis or other?
10. Suicidal Ideation: Denies. No plan/intent or other?
11. Homicidal Ideation: Denies. No plan/intent. Or other?
12. Insight: Intact or poor?
13. Judgment: Not impaired or impaired? If Impaired, what actions are you
taking to address safety?
14. Concentration and Attention: Within normal limits or not?
15. Memory: Intact or other?
16. Impulse Control: Intact or poor?
17. Intelligence: Average, below, or above?
L. Diagnosis (in a paragraph following the diagnosis with DSM5 coding, include all
symptoms that support the diagnosis according to the DSM5 as the client is
M. Treatment plan/intervention considerations
o Does the treatment plan match the diagnosis?
o Is the treatment plan and intervention suggested evidence based and not
o Are there goals that are developed between you and the patient or client
that are measurable?
o What is the schedule of therapy? When and how often will they return?
o What is the target plan for termination and are the goals and plan
measurable to show the intervention and goals were met through clear
measurements so you do not terminate and abandon a client etc.?
o Does the plan in place allow you to make clear steps in each session to
show a linear path to completion and not just notes of what you talked
about in each session?
1. Work with the client to identify a minimum of two goals. Goals should be stated as
the outcome of a successful intervention (For example: Ms. Jones will live in stable
and safe housing).
2. For each goal, identify two objectives that will result in goal achievement. Objectives
are the steps you (or your client) take to get to the goal (For example: A. The social
worker will provide a referral for Emergency Housing by sending an email with the
required form by 03/18/2016. B. Ms. Jones will provide the social worker with a
copy of her identification card and her two most recent pay stubs by 03/15/2016).
3. Identify possible obstacles and tentative approaches to prevent or address them.
Your Intervention Plan should look like this:
• Goal: Ms. Jones will live in stable and safe housing
▪ Objective: The social worker will provide a referral for Emergency
Housing by sending an email with the required form by 03/18/2016.
▪ Objective: Ms. Jones will provide the social worker with a copy of her
identification card and her two most recent pay stubs by 03/15/2016.