A case history is a record of facts from a clients background that are important as they relate to his/her present situation. Information from a clients history can help the worker in his/her assessment of the clients strengths/areas of improvement; it can also help in defining the problem.
There are several sources of historical information. Use as many as you can. Among the sources of information are:
The clients self-report
Records in agency files
Your own observation
Other workers
The clients peers
School, medical and employment records
The clients family
Included in a clients history there should be informed of several sorts:
Identification: clients name, date, and place of birth, age, occupation, material status
Physical/medical: height, weight, body proportions, coordination, general physical appearance, health, medical problems that could affect treatment, medication
Family: birth order, number of siblings, number of parents, relationship with siblings and parents, responsibilities in the home, attitude toward family, problems at home
Education: schools attended, school adjustment, favorite subjects, problems, attitude toward school, academic achievement
Vocational: jobs held, length of employment, vocational plans, present job satisfaction, training needs
Emotional: general mood, anxieties, fears and worries, interpersonal conflicts, emotional maturity, self-concept, interests, values, habits
Social/cultural: economic status, peer group, environment, recreational activities, race, religion
Assessment- Whats going on now? What made the client come to seek help?
Strengths and Areas of Improvement
Goals
Client goals are statements that describe desired changes in your clients behavior and/or attitudes. Case plans are detailed descriptions of how your agency will help the client reach each goal. The number and types of goals you must write are determined by your assessment of the clients strengths and problem areas-it will be different in each case. In every instance, however, there should be a plan for each goal.
Goals: a minimum of 3 goals with any combination of the various goals stated below
Enriching write these goals in areas where your clients assessed functioning is at Well Being. Enriching goals are intended to capitalize on areas of strength and improve the quality of life of your client.
Preventative – write these goals in areas where your clients assessed functioning is at STRESS or PROBLEMS. Preventative goals are intended to improve the clients functioning to well-being or to prevent regression to lower levels of functioning.
Rehabilitative write these goals in areas where your clients assessed functioning is CRISIS or DISABILITY. Rehabilitative goals are intended to improve your clients functioning to a more acceptable level or to help them live with an unchangeable condition
The types of goals you write will depend primarily on the levels at which you have assessed your clients functioning. For example, if your client is a nursery school student without any serious problems, you will write mostly enriching goals with, perhaps, some preventative goals. On the other hand, if your client is severely handicapped and institutionalized, you will probably write rehabilitative, preventative, and enriching goals.
All the goals you write should meet the following six criteria:
Goals should be written in SPECIFIC terms. Avoid vague statements like, better self-esteem or improved relationship with spouse.
The desired outcome as stated in the goal should be Measurable. The client, agency, and worker must have a way of knowing when the goal has been reached.
The goals you write should be REALISTIC. The client must be capable (see strengths in the assessment section) of reaching the goal.
Client goals should be RELEVANT. Completion of the goal must be beneficial to the client in overcoming a problem or enriching their life in general.
The goals should be written in a way that is UNDERSTANDABLE to the client if possible. Avoid jargon and complicated sentence structure.
Whenever possible, goals must be MUTUAL. Your clients chances for success in reaching goals will be improved, when the client, the clients family, and the agency agree to the goal.
Each goal you write should contain the following four elements:
Describe the behavior or attitude that you want to change. Include information regarding conditions under which the behavior occurs, frequency, and duration.
Describe the desired outcome.
Indicate the method of measurement. This might be observation, test results, or client self-report.
Project anticipated completion date.
