Assessments of Client Domains: (Briefly describe the client‘s status in each of the following domains. If they indicate none or choose not to answer a particular item, just note ―client declines at this time.‖ This is a valid option for any of the questions and information requested in this assessment. Case managers should never force a client to respond to something that makes them uncomfortable.)
Family: Sarah is married to John. They have 5 children: Samuel (6 months), Mark (2½ years), Claire (4 years), Kristy (6 years), Jack (8 years).
Sarah‘s parents live about 8 hours away and try to visit often. John‘s parents live nearby and offer to help, but do not have much time to actually help out.
Social: Sarah reports that she does not participate in any social activities at this time. She previously attended playgroups and parenting programs at an agency in her community called The Family Place.
Spiritual: Sarah describes herself as ―religious‖ but that she currently does not attend church. She states that it is too difficult to get everyone ready on Sunday morning.
Housing: Sarah and her immediate family live in a four bedroom home.
Employment: Sarah is currently unemployed. Before having children, Sarah was a teaching assistant in a preschool.
Access to health and dental care: Sarah and her family have medical and dental insurance.
Transportation: Sarah and her family have reliable transportation.
Hobbies and recreation: Sarah states that before she had her children that she enjoyed running, painting, and writing short stories. She previously belonged to a women‘s writing group.
Other
Current Medications:
Name/Dosage: None
Side effects:
Medication allergies:
Prescribed by:
4
Safety and Trauma History:
Are you safe in your current living situation? Yes X No
Do you feel threatened in any way? Yes No X
If yes, describe:
Are you now, or have you in the past, experiencing trauma of any kind? Yes No X
If yes, check all that apply:
Emotional/Psychological
Sexual
Physical
Provide a brief description of this and your present status. Include a brief statement of any previous treatments or services you have received for this trauma(s) and whether or not you have any remaining symptoms or issues you would like help with.
If applicable, do you have a safety plan? Yes No X
Do you need immediate help today to gain safety? Yes No X
Client’s Legal History: No Legal History
Suicide/Homicide Risk Evaluation:
Client‘s self-rating of suicide risk: 1-None X 2 – Slight 3 – Moderate 4 – Extreme/Immediate
Client‘s self-rating of becoming violent: X 1-None 2 – Slight 3 – Moderate 4 – Extreme/Immediate
Client‘s self-rating of homicide risk: X 1-None 2 – Slight 3 – Moderate 4 –
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