CUNY Lehman College Bio Psycho-Social Assessment Project

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Utilize the case material presented in Episode 6 Reservation Dogs (2022) or Moonlight (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

  1. 3. Presenting problem/need and expected outcome of intervention

as reported by the client

  1. as reported by the referring person (if applicable)

4. Onset of the problem, duration, severity

  1. 5. Past attempts to deal with problem

III. Client Description/History 

  1. 1.Relevant Developmental History

2.Family Composition and History (include family composition, family of origin history/dynamics, intergenerational themes, cultural factors)

  1. 3.Educational and Occupational History

4.Religious (Spiritual) Development

  1. 5.Social Relationships

6.Dating/Marital/Sexual Relations

  1. 7.Medical History (include illnesses/diagnoses/current medications and significant family history)

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 

V. Formulation 

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

  • cultural, racial, religious, sexual orientation and cohort factors
  • current social/sexual/emotional relationships
  • III. Client Description/History 
  • This section discusses past history as it relates to the presenting problem.  Should be as factual as possible.
  • Includes applicable information about each of the following major areas or about related areas relevant to your client. 
  • Relevant Developmental History: Pre-natal care and experience, birth problems/defects, developmental milestones including mobility (crawling, walking, coordination); speech; eating or sleeping problems; developmental delays and gifted areas. 

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.

  • Alcohol/Substance use/abuse history:This includes patterns of use/impairments, known diagnoses, treatment and outcomes for the client and within the family.A helpful tool to assess alcohol/substance use is the cage (for adults) and crafft (for adolescents).

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). 

  • Briefly describe significant areas of functioning in the client’s life (i.e., work, home, social). 
  • Identify stressors in area and the client’s coping style in relation to stressors. 
  • Identify intrapersonal/interpersonal, social/political and environmental strengths the client uses to maintain functioning. 
  • State barriers and risks affecting the client’s coping abilities–environmental, interpersonal/intrapersonal, social/political
  • V. Formulation
  • This section is based on initial observations and information gathering. The worker integrates their understanding of the client’s problem or situation, its underlying causes and/or contributing factors with the self of the client—who they are, how they developed, who they have become, their strengths, resources and potentialities.
  • The worker summarizes their understanding of the client’s current life situation drawing upon knowledge of the social, cultural, familial, psychological, economic, environmental, systemicfactors that function to maintain the current situation, and those factors that are strengths and resources at each of these levels that will support solutions to the problem.

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,

  • motivation and commitment to treatment)

Psychological factors–reality testing, impulse control, judgment, insight, memory or

  • recall, coping style and problem-solving ability, characteristic defense mechanisms,

notable problems. If applicable, include a formal diagnosis (e.g., DSM IV-TR, Global

  • Assessment Scale, etc.)

Environmental issues and constraints or supports from the family, agency, community

  • that affect the situation and its resolution. What does the environment offer for

improved functioning (family, friends, church, school, work, clubs, groups, politics,

leisure time activities).

  • Issues related to cultural or other diversity that offer constraints or supports from the

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.

  • VI. Intervention Plan

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: 

  • resources or limitations; community resources or limitations.

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