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

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

5. 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

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

7. 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

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

9. Assessment
Dimension 9: Motivation
Values & strengths
Hopes & dreams
Client readiness/stage of change
Dimension 10: Diagnosis
Current: Axis I-V; soon to change
MSE & clinical impressions
Recommendations/plan
Assessment procedures

10. Assessment
Dimension 9: Motivation
Values & strengths
Hopes & dreams
Client readiness/stage of change
Dimension 10: Diagnosis
Current: Axis I-V; soon to change
MSE & clinical impressions
Recommendations/plan
Assessment procedures