Individual Biopsychosocial Assessment: A Case Study

Students will complete an individual biopsychosocial assessment, including goal setting and implementation of a change strategy (e.g. therapeutic approach) for either a real or a fictional client. For students who are presently enrolled in a practicum, and if it is feasible and appropriate to do so, they will be encouraged to use a real client (names and personally identifiable information must be changed for the purposes of the assignment). If a real client is not practical, a fictional client from a television series (In Treatment) will be used instead. If using a fictional client, students will need to imagine, based on the presentation in the show, what the client’s goals might be and what change strategies the student social worker might

Outcomes and goals

Cindy Lou Who states she wishes to obtain services in order to be compliant with her drug court probation. She hopes to obtain sobriety in order to clear her criminal record. Her short term goals are to enroll in substance abuse and mental health treatment. Her long term goals are to obtain employment, her own home and return to school to gain a Associates degree.

Suicidality/homicidally

Cindy Lou Who reports no thoughts about committing suicide in the last week. However she does think about suicided often. She has attempted to take her life once in the last year. Cindy Lou Who reported that she has not had any thoughts of hurting someone else last three months. She reported that she has not made homicidal times in the last three months.

Treatment history

Cindy Lou who has not participated in treatment within the last 90 days. She attempted inpatient services three years ago. However she felt her substance abuse was not as and as other patients and checked herself

Police found controlled substances in her possession. She was arrested and served 30 days in jail requesting drug court therefore a felony was not on her record. This being the reason why she was referred for substance abuse/mental health assessment.

Bereavement/trauma/abuse

Cindy Lou who reports that she experienced trauma due to emotional abuse by her step mother as a child. There is no stress related to bereavement.

Childhood family

Cindy Lou who reports the following family dynamics her childhood was difficult, because of the emotional abuse.

Living situation

Cindy Lou who currently lives with her grandmother. She lost her job recently therefore she does not have enough money to pay bills her own home.

Educational/vocational

Cindy Lou who is currently unemployed. She has no military prior status to report.

Strengths/recovery

Cindy Lou who reports the following strings and recreation activities She enjoys crafts music art and exploring. The following are social supports friends who are silver and family members. She reports having community resource access such as Medical Card and Link benefits. Cindy Lou who reports that she believes in God but does not, Practice religion.

Diagnosis DSM-V/ICD