Follow this template exactly: DESCRIPTION OF THE CLIENT SYSTEM: a) Client/Family Identifying Information b) Reason(s) for services c) Household Members (to include relationships with one on another, and their patterns of functioning) d) Household Living Conditions ( environmental, factors) e) Financial History (to include all insurance information, excessive debt, etc.) SOCIAL RELATIONSHIPS AND SUPPORTS a) Family History: In this section, you will include a family Genogram of at least 3 generations. Present data on family members (be sure to designate the members living in the household). Names, gender, birth dates (or ages), relationships, marriage dates, education, occupations, deaths (causes), chronic conditions (e.g. alcoholism, mental retardation), significant trauma (e.g. fire, rape, incarceration), anything significant to describing individual. Other data that may be significant: adoptions, miscarriages, pregnancies, separations, current locations, etc. b) Community System: Complete an Ecomap (Depict the connections with various systems. Describe relationships between client/family members and the various systems. Describe community context and include a description of neighborhood resources. (Remember to include a key to explain the type of relationship or connection) c) Assets and Resources: Information about the clients informal sources of support. Information about the client primary and secondary sources of support. The type (what need does the source meet) and frequency (how often) of support from whom (., friends, extended family members, church, etc.) provides support? Assess if the support provided is reliable SOCIAL HISTORY: a) Physical Health (past and present, make certain to include any medication schedules, family history of medical conditions (ADL, IADL) b) Mental Health: This section will include a brief history of family psychiatric problems. Report whether client has a history of psychiatric disorders; admission into mental health clinic (inpatient or outpatient), dates receiving services, outcome of services, medication, treating therapist (past or present); family history or mental disorders. History of homicidal and suicidal ideation (MMSE, GDS, DSM5) c) Alcohol and Drug Use: Summarize if client used any substance in lifetime (. cigarettes, marijuana, cocaine, etc.). Periods of sobriety and treatment (when, where and with whom); describe outcome of treatment (SMAST-G). d) Sexual History: Describe sexual activity, sexual orientation, physical, sexual abuse (victim/offender). Explore if relevant to problem situation. It is appropriate to assess if client practices safe sex and receives regular physical check-ups. If client reports being diagnosed with sexual disease, it is appropriate to explore, medication received, primary physician, etc. e) Educational: Describe clients educational background, highest level of degree attained. Difficulties in school (why, where, when); special education needs; suspensions. Include any informal educational skills. If client did not graduate from high school or received a GED, explore what barriers were present. f) Employment? Work History: Summarize clients type of work; attitudes toward work, reasons for leaving or being fired from previous jobs. Also, include any voluntary work (. community, church, etc.). Make sure to include any military experience and informal employment. g) Recreational: Describe their activities or interest they enjoy, such as hobbies, sports, or leisure pursuits, special talents or skills. Are they involved in any church related activities (. bible school, bible camp)? h) Cultural Family Norms: Describe cultural beliefs; rituals, patterns. Do they have family reunions or times when they come together (outside of marriages and funerals? i) Religious/Spiritual: Describe if client identifies with a particular religion or faith. Describe how client expresses spirituality. Describe clients current and past religious and spiritual practices. Describe if client is associated with a place of worship. Describe if their religion or spirituality is helpful to them. j) Strengths and Competencies: Describe client/family strengths, capacities, abilities, competencies and resources that may help to address and resolve the issues of concern. INTERVENTION Describe in detail the intervention(s) utilized to assist the client.
