Format for a Bio - Psycho - Social - Spiritual - Cultural Assessment Report

Format for a Bio-Psycho-Social-Spiritual-Cultural Assessment Report

Complete a bio psychosocial assessment on your dyad partner’s character. A bio-psycho-social-spiritual-cultural assessment describes the client's story, taking into account personal, biological/physiological, psychological, and social factors that may have bearing on the client’s life situation.  It functions as a prerequisite to intervention.  The client situation must be thoroughly understood, eligibility for service determined, and capacities for change assessed.  The social worker observes verbal and nonverbal behavior and identifies factors that affect social functioning.  Once the situation has been assessed, the social worker writes a report, which is used to formulate a case plan.

Course Objectives Directly Targeted in this Assignment

• Analytical & interactional skills for implementing social work processes (5107 objective #4);
• Competence in conducting ongoing, comprehensive, multidimensional assessments, explaining the relationships among the systems “from individual to institutional/personal to political” in relation to a focal client system or condition (5107 objective #8);
• Skills in communicating competently, both orally and in writing, in professional and academic settings (5107 objective #10)

Please type in 12-point font.  Unless otherwise noted in the instructions below, the assessment should be written in full sentences and paragraphs.  Please use headings and subheadings.  They help both you and your reader to find important information quickly.

Note that sample questions are in italics to assist you when interviewing your dyad partner.

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1. Client Identification & Contact Information—In this section, provide information that helps to identify the client and other relevant persons.  It is okay to list this information rather than write it out.

1. Name  Sharon Marks
2. Sex (biological)  female
3. Date of birth  04/25/1978
4. Current living situation   1251 N. 12th St Philadelphia, Pa. 19132
5. Current place of work      Secretary at Liberty Mutual  1207 Market St.
6. Contact information:  landline, cell, pager, email, etc.  215.765.2702
7. Date(s) of assessment.  9/25/2013

1. Description of Person System, Family/Household/Primary Social System, & Ecological System—Be sure to write a narrative for each of the subsections below.  Genograms and ecomaps should supplement the written narrative.

1. Person System – Present information describing the prospective or identified client.  Information such as height and weight, race and ethnicity, physical appearance, striking or characteristic features, speech patterns, health, and clothing may be included.  
2. Sharon is approximately 5’4”  150 lbs.  Bi-racial African American and Puerto Rican, with a well groom appearance, elaborate ethnic hair style and color co-ordinated attire, very stylishly done. Communicated with precise diction and good vocabulary. She appears younger than 35, and seems to be in good health as evidenced by her movement and body language.

1. Physical appearance—provide enough information so that someone could pick them out of a waiting room.

1. Gender (sociological)
2. Race and ethnicity
3. Do they look their age?
4. Height and weight
5. Do they look healthy or sick?
6. Striking or characteristic features
7. Clothing

1. Family/Household/Primary Social System—Describe the client's family, household, or primary social system.  Use a genogram, which you can reference in your narrative and attach it as an appendix.

1. Family of origin Not with her husband so she is alone in terms of relationships. The relationship with her mother is slowly improving, it has been problematic in the past. Sharon enjoys a fine relationship with her only sibling a sister, Kelly.

1. Close or fractured?  Fractured but healing with the mother, close with the sister. Her husband is incarcerated and attempts communication but is currently being rebuffed by Sharon. The court allows some communication with the son, James, who is 4 years old. James is upset and angry with the family break-up and not being with either parent. James is in the custody of Kelly. But Sharon has full access to her son, seeing him three times a week at least and every other weekend, sometimes every weekend depending on circumstances.
2. Do they express emotions?  Sharon can talk to Kelly about everything, and not be judged. Her mother can’t understand her lifestyle or choices, and feels that her choices have led to her present situation. Participant is depressed at times but tries to cope.

1. Extended family

1. History of physical illness, substance use, and mental illness (First degree and then second degree) Participant claims that there is no history.

1. Any history of diagnosed psychiatric illness, like anxiety, depression, alcoholism? Participant does not think that there is much of this in the family. The mother was in a depressed state following the death of the father, but appeared to recover and get back into normal life patterns.
2. Anything not diagnosed, but you highly suspect? Two of her three uncles have medical conditions but not really mental health. Several cousins are autistic.

1. Marriages/divorces, partnerships/break-ups, births, deaths, etc.

Aside from the remarriage of her mother after the death of her father, the other marriages appeared in the normal course of life events. Kelly is happily married and most of the aunts are married. A large support system at most times with seven aunts by blood and two by marriage.