1. Chapter 8
Assessment

2. Assessment
Goal
Address historical information
Uncover richer elements & how they relate to each
other
More than just behavior
Assessment process
Time frame
Overview to client
Go with client flow
Documentation

3. Assessment
Goal
Address historical information
Uncover richer elements & how they relate to each
other
More than just behavior
Assessment process
Time frame
Overview to client
Go with client flow
Documentation

4. Assessment
Dimension 1:
Presenting Issue/s
What brings the person?
 Self/family
 Referral
Understanding their
perspective
View on issue
 Problem?
 Priorities
 Initial motivation

Dimension 2:
Treatment history
Background information on
presenting issue
Prior history and
experience
Current reflections
What helped/didn’t help

5. Assessment
Dimension 3: Substance use history
Now & in the past; build on screening
Substance
Frequency
First Last
 Amount
Use Use
 Age at first use
 Last used
 Administration
 Overdose, etc
 Patterns (now & in the past)
 Periods of abstinence
 Family history

Pattern
Rout
e of
admi
n

6. Assessment
Dimension 4: Medical history
Known conditions
Exams/providers/hospitalizations
Unmet medical needs/risks
Medication
Family history
Dimension 5: Basic needs
Being met?
ADLs
Referrals

7. Assessment
Dimension 6: Psychological functioning
Known MH conditions
Trauma
Hospitalizations
History, pattern with/without SA
Risks
SI/attempts
 History
Family history


8. Assessment
Dimension 7: Family history & structure
“Who is family”/basic stats
Family relationships/dynamics/estrangements
View on family
Dimension 8: Social/cultural contexts
Environment/living situation
Community resources/outlets
Stressors
Financial
 Housing


9. Assessment
Dimension 8: Sub-dimensions
Cultural/spiritual values, beliefs & strengths
SES
Vocational history
Educational history
Social-relational
Legal history
Arrests
 Incarcerations
 Current status


10. Assessment
Dimension 9: Motivation
 Values & strengths
 Hopes & dreams
 Client readiness/stage of change
Dimension 10: Diagnosis
 Diagnoses (SUD; MH; Medical)
 Psychosocial/environmental stressors
 MSE & clinical impressions
 Recommendations/plan
 Assessment procedures
Attend to cultural factors throughout entire
assessment process