HUS 335: Interpersonal Helping Skills Case Assessment Format The case assessment takes place after the intake and assessment interviews have been conducted. The helping professional must evaluate the application for services to determine eligibility for services. This is just one process for conducting a case assessment. Step 1. Provide me with your agency’s profile with your eligibility guidelines (on a separate page) Step 2. Review the case assessment process (things to think about as you complete the assessment) Step 3. Complete the Case Assessment (p. 2) I. Examine your agency’s guidelines for eligibility as well as federal or state guidelines, if applicable. What are your agency’s guidelines for eligibility? II. Review all the information you have gather on your client during the initial contact, intake, and assessment phases. a. Applicant’s reason for applying for services b. His/her background c. Strengths d. Weaknesses e. The problem that is causing difficulty f. What the applicants want to have happen as a result of service delivery III. Determine if the client is eligible for services at your agency. A. Is the client eligible for services? Why or why not? B. What problems are identified (i.e., presenting problem)? C. Are services or resources available that relate to the problems identified? D. Will the agency’s involvement help the client reach the objectives goals that have been established. E. Is more information needed (e.g., referral source, client’s family, chool officials, employer, medical doctor, mental health professional, previous social service agencies, etc.) IV. Impressions V. Assessment VI. Service Identification/Recommendations for Services VII. Case Assignment Your Agency’s Name Case Assessment Pseudo Client Name: ____________________________________________ Date: _________________ Human Services Professional: ______________________________________ Title: _________________ Intake Date: ______________________ Assessment Interview Date: _________________________ I. Demographic description of client Age, gender, cultural background, race, socioeconomic status, religion, occupation, marital/family status, education II. Presenting Problem Indicate referral source (e.g., self-referred or agency referral). If an agency referred the client, state why they referred the client to your agency. State what brought the client to your agency from the client’s perspective. (This only needs to be a few sentences and not the history of the client.) III. Impression/Interview affect, behavior, and mental status How does the client appear to you (grooming, dress, voice, tone, mood, timeliness for the interview, cooperativeness, etc.)? Has this been consistent or changed throughout sessions (intake and assessment interview sessions)? IV. History Present the history as objectively as possible and only key information. Facts that were collected from the client, significant records, and referral source. Let the facts s ...

1. HUS 335: Interpersonal Helping Skills
Case Assessment Format
The case assessment takes place after the intake and assessment
interviews have been conducted. The helping professional must
evaluate the application for services to determine eligibility for
services. This is just one process for conducting a case
assessment.
Step 1. Provide me with your agency’s profile with your
eligibility guidelines (on a separate page)
Step 2. Review the case assessment process (things to think
about as you complete the assessment)
Step 3. Complete the Case Assessment (p. 2)
I. Examine your agency’s guidelines for eligibility as well as
federal or state guidelines, if applicable. What are your
agency’s guidelines for eligibility?
II. Review all the information you have gather on your client
during the initial contact, intake, and assessment phases.
a. Applicant’s reason for applying for services
b. His/her background
c. Strengths
d. Weaknesses
e. The problem that is causing difficulty
f. What the applicants want to have happen as a result of service
delivery
III. Determine if the client is eligible for services at your
agency.
A. Is the client eligible for services? Why or why not?
B. What problems are identified (i.e., presenting problem)?
C. Are services or resources available that relate to the
problems identified?
D. Will the agency’s involvement help the client reach the

2. objectives goals that have been established.
E. Is more information needed (e.g., referral source, client’s
family, chool officials, employer, medical doctor, mental health
professional, previous social service agencies, etc.)
IV. Impressions
V. Assessment
VI. Service Identification/Recommendations for Services
VII. Case Assignment
Your Agency’s Name
Case Assessment
Pseudo Client Name:
____________________________________________ Date:
_________________
Human Services Professional:
______________________________________Title:
_________________
Intake Date: ______________________ Assessment Interview
Date: _________________________
I. Demographic description of client
Age, gender, cultural background, race, socioeconomic status,
religion, occupation, marital/family status, education
II. Presenting Problem
Indicate referral source (e.g., self-referred or agency referral).
If an agency referred the client, state why they referred the

3. client to your agency.
State what brought the client to your agency from the client’s
perspective. (This only needs to be a few sentences and not the
history of the client.)
III. Impression/Interview affect, behavior, and mental status
How does the client appear to you (grooming, dress, voice,
tone, mood, timeliness for the interview, cooperativeness, etc.)?
Has this been consistent or changed throughout sessions (intake
and assessment interview sessions)?
IV. History
Present the history as objectively as possible and only key
information. Facts that were collected from the client,
significant records, and referral source. Let the facts speak for
themselves. Do not interpret them. Use verbatim quotes from
the client and others. Each section can be brief.
a. History of presenting problem
Estimated date of onset, intensity, frequency, and changes (e.g.,
when did the client become homeless?) How long has this been
going on? How often? Use quotes.
b. Family history
Include marital status of parents and any dates of family
structure changes or deaths. Include a description of
relationships with family members and living arrangements.
Include a statement affirming/denying substance abuse, physical
abuse or sexual abuse among family members, if appropriate.
c. Social relationship history
How are relationships with friends, peers, coworkers, church,
etc.? How were the relationships before and after the problem(s)
started? Describe support system.

4. d. Academic/work history
Highest level of education. Any academic or work aspirations.
What work skills exist?
e. Medical history
Past and present medical conditions, hospitalizations,
prescription medicines, problems with eating, sleeping, weight
control, alcohol and substance abuse. When was the last
physical? Do they have a primary physician?
f. Other Agency Involvement history
Past or present involvement with other human services agencies.
V. Assessment
Provide your understanding of the client’s problem based on an
interpretation and synthesis of the information assembled on the
client. Give rationale by using the facts to justify your
definitions of the problem. Include impressions of client’s
strengths and weaknesses. Identify measurable goals and
objectives for the client.
VI. Recommendations for Services
What services will your agency provide to this client? What
services will you refer the client for that are not provided by
your agency but the client needs? What are your suggestions for
future work with this client in Human Services?
VII. Case Assignment
Is the client eligible for services at your agency? Why or why
not? Who will be assigned this case at your agency (e.g., case
manager, a team, etc.)?
VIII. Critical Thinking
Choose two Saint Leo University Core Values that your agency

5. holds as values when helping clients. Explain how two
Standards in Human Services (National Organization for Human
Services) are important to your agency. Explain how the goals
and this plan can be useful to the client in Human Services.
How would you bring about change to the client and other
systems?
Scoring Rubric for Case Assessment and Presentation (CA)
Please copy this guideline and place it after your title page with
your name on it when you start writing your paper. This
guideline will be used for evaluation/grading. Please tear this
off your syllabus and attach to your paper when you submit it.
The instructor will grade your paper according to this rubric and
give it back to you. In this way you can see what you did well
and what you need to improve for future papers and work in
Human Services.
Name:_______________________________________________
_______________________
Evaluation/Grading Criteria:
Criteria/Point Value
Comments
Total Points 100
Organization 20 points
· Title page
· CA –guidelines (copy it)
· Paper (no more than 10 pages)
· Assessment Format as outlined in text
· APA 6th edition
· Introduction – student name, case name, type and name of
agency
· Clear & logical structure
· Effective use of headings, subheadings, correct grammar and

6. spelling, no typos – smooth transitions and coherent
Evidence 40 points
· Student’s original work of CA and professional opinions
adequately supported with references to
text or other professional sources related to
case assessment
· Sources cited in the text using APA 6th format
· The Assessment includes the problem formulation with
descriptive information on the client
· The Assessment includes a thorough history of the client
problem, intake, and contract which includes measurable goals
and objectives
· Two Saint Leo University Core Values are included.
· Explain how two Standards in Human Services are supported
Critical thinking 40 points
· Usefulness of your CA and how the plan and goals can be
useful to the client in Human Services (HS) – are described in
detail.
· How would you bring about change to the client and other
systems?
· What are your suggestions for future work with this client in
Human Services – provide recommendations?
Case Development
Information to collect when conducting an initial interview or
include when developing a sample case. This information would
be gather doing the assessment phase. The guide was gather
from http://www.become-an-effective-

7. psychotherapist.com/Case-Presentation.html on 8/27/17
1. Demographics
Demographics include the client’s name, age, gender,
relationship status, ethnicity, occupation, length of employment,
age and gender of any children.
Example: Mary T. is a 25 year old married bi-racial female who
has worked for City Savings and Loan as a teller for the last 2
years. She has been married to her husband for 4 years. They
have no children and no previous marriages.
2. Presenting problem
The presenting problem is the reason why the person is
receiving your services. The presenting problem can also be
called the client’s chief complaint.
Example: Mary presents with multiple concerns related to an
unfulfilling marriage, potential loss of employment, and
concerns over her husband’s gambling.
3. Goal
Clients come to therapists to accomplish something. I think it is
a good idea to find out what the client’s goal is. What do they
want to get from your agency?
Example: Mary would like to first focus on concerns related to
her husband’s gambling. Mary states that her husband told her
last week that he is approximately $45,000 in debt. Mary is also
worried about her job security.
4. Legal/ethical
This is a one of the most critical categories. Not addressing
your legal and ethical responsibilities can be legal problems for
you.
· You must indicate your status as an intern, if this is the case.
· You must provide the name of your supervisor.
· You must provide a written Informed Consent that usually
includes information about the limits of confidentiality, your
responsibilities in reporting abuse, your fee, your cancellation
policies, and what the client should do if an after-hours clinical
emergency happens.
· Provide proper HIPAA notification, if you or your office is

8. considered a “covered entity.”
· If seeing a couple, it is always a good idea to discuss your
“secrets” policy.
Make sure you know what your legal and ethical responsibilities
are at all times. If you have any questions, please ask your
supervisor or someone licensed in your field of study.
Generally, your legal and ethical responsibilities include:
Example: Mary signed the Informed Consent. She was notified
of my status as an intern and the name of my supervisor. She
was verbally informed of the limits of confidentiality,
cancellation policy, and office fees. Mary signed the
Acknowledgment of HIPAA Guidelines form.
5. Crisis/safety
Is the client in crisis? If so, describe the type and severity of
the crisis and your interventions to address this concern. You
must be exact.
Example: While her situation is difficult, Mary does not appear
to be in crisis at this time. She denied any thoughts or feelings
related to self harm. She denied any past history of self harm.
There are no reporting responsibilities present. She seems to
have an active and extended support system.
6. Diversity
What are the differences between you and the client? These
differences can be about age, gender, education, socioeconomic
status, sexual orientation, marital status, religion, stage of life,
and should be noted.
The concern is whether or not these differences pose a difficulty
for the helper to remain objective and focused on the client’s
concerns. If the differences between the client and therapist are
too great for the helper, it should be noted how the helper will
handle this problem.
Example: There are some differences between Mary and myself.
While we are of the same gender, she is married and I am not.

9. Mary is of a different ethnicity than I am and she is a few years
younger than I. There may also be some differences in our
educational background, as well. I do not feel these differences
will impede our working together. If I felt otherwise I would
discuss my concerns with Mary to see if she had any similar
concerns. Secondarily, I would seek consultation from my
supervisor or a clinician skilled in working with someone from
her culture. If the differences between us were too great and I
was not of optimal service to my client, I would provide her
with an appropriate referral.
It is a good idea to state that despite the differences between
you and the client you feel confident you can be of service. If
the differences were too great you should discuss your
limitations with your supervisor and get consultation from a
clinician of more similar backgrounds. Or you can refer the
client to a therapist with more similar demographics to the
client than you have.
7. Assessment
Your assessment is your impression of the client based on the
assessment questions you asked.
Example: Mary is devoted to her husband and family, but is
clearly struggling with their financial difficulties. She
complains about increased anxiety, decreased sleep and some
disruption in concentration. She notes a change in mood as she
is “worried all the time” and finds herself crying when she feels
hopeless. Mary does not describe herself as a person who
worries a lot. Her acute symptoms seem particular to her
husband disclosing the extent of his debts. She states her
appetite is stable and has not experienced any recent gain or
loss of weight. She is oriented to person, place and time.
Thinking is linear and her memory appears good. Affect
matches content. She states her performance at work is affected
by her personal worries, but there is no current disciplinary
action against her. She denies any suicidal or homicidal
ideations or actions in the past or present. She states a social

10. use of alcohol. She apparently has a strong support system
which includes a large extended family and strong ties to her
church community. She states her husband is generally
supportive, they are effective parents, but has been less
available due to his own worries. He has been avoiding her.
Name: ______________________________________
Date: _________________________
Eco-Map
Case:
Goals:
1.
2.
3.
KEY
= Strong/Positive Relationships
= Very Strong Relationship
= Weak/Negative Relationship
= Stressful/Adverse Relationship
= Strained Relationship
= Male
= Female

11. From the Perspective of:
_____________________________________
Print & Signature
_____________________________________
Helper Name & Title
_____________________________________
Helper Signature
Name: ______________________________ Date:
______________________________
ECO – MAP
Purpose: To have a visual depiction of one’s life/relationships
to help identify strengths and stressors which can affirm for
them their feelings of depression, anxiety, or even pride at the
strengths they have developed.
Case Description:
The components to include:
· A brief description of who the client is
· What services are needed
· Previous services received
· Referral type
· Describe initial contact
Case History:
The components to include:
· Identify the client
· Demographic information about the client (e.g., age, gender,
marital status, # of children, employment status)
· Presenting problem
· Identified strengths
· Support system

12. · Important relationships
Key/Legend:
Include all of the symbols used in the Eco-Map. It may need to
be on a separate sheet.
HUS 335: Interpersonal Helping Skills
Rubric for Eco Maps (15%)
Name: _________________________________________
Date: __________________
PRESENTATION
Excellent
Good
Average
Below Average
Poor
Not
Included
TOTAL POINTS
Identified Client
Rapport Building
Interview
5
4
3
2

13. 1
0
5
4
3
2
1
0
Theory
Identified a theory that may fit the study; identified the founder
of the theory; when the theory was developed
5
4
3
2
1
0
Ethical Issues
Identified potential ethical issues; deception, confidentiality;
informed consent
5
4
3
2
1
0
Literature Review
At least 5 researched articles (peer-reviewed) used; discussion
of previous studies and their relation to the topic; identified
components relevant to the research proposal
5

14. 4
3
2
1
0
Methodology
Identified the sample, procedures, and instrument(s)
5
4
3
2
1
0
Reference
Cited references in text and have a reference list in APA format.
Professional & engaging presentation
Dressed professionally

15. Good voice/tone quality
Used proper grammar
Made eye contact
Knowledgeable of the topic
Includes not reading directly from PowerPoint or notes

16. Overall quality of presentation
Worthwhile attending – organized, interesting, great effort made
(exceeded expectations w/charts & graphs), showed passion
Comments: FINAL
GRADE: _________
30
points