Chapter 8
Assessment
Assessment
Goal
Address historical information
Uncover richer elements & how they relate to each

other
More than just...
Assessment
Goal
Address historical information
Uncover richer elements & how they relate to each

other
More than just...
Assessment
Dimension 1:

Presenting Issue/s
What brings the person?
 Self/family
 Referral
Understanding their

persp...
Assessment
Dimension 3: Substance use history
Now & in the past; build on screening
Substance
Frequency
First Last
 Amo...
Assessment
Dimension 4: Medical history
Known conditions
Exams/providers/hospitalizations
Unmet medical needs/risks
M...
Assessment
Dimension 6: Psychological functioning
Known MH conditions
Trauma
Hospitalizations
History, pattern with/w...
Assessment
Dimension 7: Family history & structure
“Who is family”/basic stats
Family relationships/dynamics/estrangeme...
Assessment
Dimension 8: Sub-dimensions
Cultural/spiritual values, beliefs & strengths
SES
Vocational history
Educatio...
Assessment
Dimension 9: Motivation
 Values & strengths
 Hopes & dreams
 Client readiness/stage of change

Dimension 1...
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Chapter 8 14

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Chapter 8 14

  1. 1. Chapter 8 Assessment
  2. 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. 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. 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. 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. 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. 7. Assessment Dimension 6: Psychological functioning Known MH conditions Trauma Hospitalizations History, pattern with/without SA Risks SI/attempts  History Family history 
  8. 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. 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. 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

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