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It is recommended that you conduct a comprehensive psychosocial assessment or a multidimensional assessment. Use the headings and subheadings listed here as a guide only. You may have other headings which you see as relevant to your scenario, and some headings will not be relevant. The headings provide an outline of the fundamental questions to use in conducting an initial assessment. You would use this as a starting point.

You need to think about diversity in family and cultural contexts: Intrapersonal, social, environmental and cultural factors. You should also think about potential areas of risk, violent behaviour, crisis, transference, resistance or other eg. family breakdown, strengths and supports? Use the literature to support your approach.

Critically analyse the application of the process in relation to the specific practice setting. This means you must consider the strengths and barriers to using the template/headings, process and relevant tools (if used/relevant). Support with evidence (eg sources: text, journal articles, reports).

I. Objective information

1. Identifying information

Kyra is middle age women in her early forties, Kyra comes from Myanmar (Burma) originated from the Shaw Karen people from a small village near by Myanmar Thailand borders. Kyra was referred to the agency having difficulty with her traumatic past, troubles sleeping and unemployment. Kyra was referred to the agency by external agency

Demographics (age, gender, ethnicity, residence, etc.)
Reason for admission, clinic visit, or agency involvement
Reason for referral to practitioner:
• Who referred the client to your agency?
• What is the relationship with the referrer?
• Do they want or expect the referrer to have ongoing involvement in their situation?
• Do they give consent for you to contact the referrer for further information or to collaborate in providing service
What is the date of birth (ages of each)
Where do they live?
Who do they live with?
Are there any privacy issues of concerns that would make contacting them difficult (i.e. Older adolescent who does not want parents to know they are accessing a service; conflictual relationship with a partner
What are the contact details?
What is their employment?
What is their level of education?

1a. Presenting problem/issues
What is the current problem that the client is presenting?
• What precipitated the event - why is the client seeking help now?
• Is this something that has happened suddenly or has the problem evolved over time?
• Was the client overwhelmed by the sheer enormity of the stress or was it idiosyncratic?
• Is there something in the history that predisposes the client to experiencing this type of problem e.g. learning problems
• What if anything has changed and motivated the client to seek help?
• What is the history of the presenting problem?
• How long has the problem been occurring?
• When was the problem first noticed?
• Who, if anyone, has been consulted about the problem?
• What treatments or interventions have been tried before?
• What was helpful about these interventions?
• What was not helpful?

2. Family background
Family of origin or childhood
Current relationships
Adult family and significant others
Living situation-past, present, and anticipated

• Psychosocial - Who is in the family?
? What is the current family situation?
? What is the family history?
Relational
Medical
Social

3. Social history
• Educational history
• Work history (including military background)
• Friends-relationships
• Cultural influences
• Places of residence
• Substance use history
• Legal involvement

4. Financial status
• Income, expenses, obligations
• Insurance-medical coverage and needs

5. Psychosocial situation
• Cognitive status
• Emotional/psychosocial status
• Psychiatric-mental health history
• Family reactions, relationships, support, and adjustments
• Sexuality concerns (e.g., questions, orientation, problems)
• Judgment/planning-behavioural situation
• Other relevant issues

6. Tools or techniques
• Genogram
• Ecomap
• Social history
• Timeline
• Other

II. Impressions
1. Personal strengths and limitations
2. Social supports-friends
3. Resources - community

III. Plans

1. Counselling and direct services-individual and significant others

2. Social interventions, planning and advocacy
What interventions might be useful?
What type of plans - case plans etc?

3. Micro, meso, macro interventions
What information do you need?
What are the potentials of the situation?
What personal strengths does this client bring with them?
What are the strengths in their immediate context? Family, friends and close others?
What are the strengths in their community?
What supports are available?

4. Anticipated outcomes

You should provide a very concise case note here (approximately 200 words). It does not need to be referenced and should reflect real world practice context. Use your imagination here about a brief conversation you would have with your client and construct a case note based on this conversation.

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