Case Study
Engagement, Assessment, Intervention, Termination and Evaluation
This assignment will examine clinical strategies utilized in advanced social work practice with individuals
and/or families. Your instructor will provide a case study. This is a professional paper; it should be at least
15-20 pages in length (not including the cover page or references), typewritten, one and a half spacing and in
APA style of writing. The Biopsychosocial Assessment is one form of specialized assessment. The Mental
Status Exam is another assessment tool. Other specialized assessment tools will have to be researched. Use
of more than one assessment tool is common to reach a diagnosis or to adequately assess clients needing
help.
Outline
Introduction of the Case
Engagement
1) Discuss specialized engagement skills with this particular client.
Assessment
2) Specialized assessments including a biopsychosocial-spiritual assessment (include it in the appendix),
mental status exam, specific assessment tools utilized to help identify and define the problem/s, a
description of the clientàinterpersonal behavior and emotional processes, that either support or discredit
your assumptions, discussion of cultural influences and DSM 5-TR diagnosis with qualifying examples.
Also, include any other screening/assessment tools to evaluate the problem.
Intervention
1) Specialized intervention strategies, techniques and modalities including a behavior/treatment plan (with
goals and objectives that are measurable and observable), cultural and human diversity issues impacting
treatment.
Termination
1) Identify indicators that treatment is in the termination stage and specific strategies how to terminate
treatment with this particular client. Include issues related to closure, celebration, follow-up plans,
processing feelings and referrals for this particular client.
Evaluation
1) Strategies and at least one instrument to evaluate the treatment program (beginning, middle, and ending).
The evaluation must identify how assessments are used to determine evaluation and goal attainment.
Conclusions about the Case and the process
Biopsychosocial Assessment
Demographic data
DATE:
CLIENT NAME:
DOB:
AGE:
GENDER:
ADDRESS:
PHONE (HOME/CELL/WORK):
START TIME:
DURATION:
Primary method of communication:
Referral source:
Funding source:
Completed assessment with:
Current symptoms
Cognitive functions:
Dangerous behaviors & immediate threat to personal safety:
Indicators of personality disorder:
Emotional/psychiatric history
Prior outpatient treatment:
Prior inpatient treatment:
Prior residential treatment:
Date of most recent psychiatric assessment:
Current psychotropic medication:
Prior psychotropic medication:
Family members4reatment history
Has any family member had outpatient treatment?
Has any family member had inpatient treatment?
Has any family member used psychotropic medications?
Family history
Family of origin
Present during childhood:
Parents#urrent marital status:
Describe childhood family experience:
Emancipation from home:
Special circumstances in childhood:
Current family
Marital status:
Intimate relationship:
Relationship satisfaction:
List all persons currently living in clientàhousehold:
List all children not living in clientàhousehold including frequency of visitation:
Describe any past or current significant issues in intimate or immediate family relationships:
Client abuse & trauma history
Description of abuse etc.:
Concerns/needs/issues/services accessed/linkages needed:
Description of trauma:
Concerns/needs/issues/services accessed/linkages needed:
Medical history
Current medical problem(s):
Significant medical history:
List all non-psychotropic medication currently taken:
Nutritional development:
Concerns/needs/issues/services accessed/linkages needed:
Substance use history
Substance abuse history
Family substance abuse history
Concerns/needs/issues/services accessed/linkages needed:
Developmental history
Physical development:
Chronological age:
Prenatal history:
Birth:
Delayed developmental milestones:
Sensorimotor functioning & motor development:
Concerns/needs/issues/services accessed/linkages needed:
Educational development
Last/current grade completed, and school attended:
Elementary, middle/high and college/vocational training schools:
If received special education services:
Concerns/needs/issues/services accessed/linkages needed:
Developmental history (child and adolescent client)
Emotional development:
Mood:
Emotional/behavior problems:
Concerns/needs/issues/services accessed/linkages needed:
Cognitive development:
Cognitive problems:
Concerns/needs/issues/services accessed/linkages needed:
Social development:
Social problems:
Concerns/needs/issues/services accessed/linkages needed:
Socio-economy history
Current living situation:
Daily living skills:
Social support system:
Sexual history:
Military history:
Type of discharge:
Employment:
Financial situation:
Concerns/needs/issues/services accessed/linkages needed:
Legal history/status:
Cultural/spiritual/recreational status:
Spiritual/religious affiliation:
Cultural/ethnicity affiliation:
Community involvement/recreational status:
Guardianship status:
Mental status examination
Appearance:
Manner:
Attitude:
Consciousness:
Affect:
Prevailing mood:
Thought processes:
Content:
Associations:
Speech:
Faculty orientation:
Attention span/concentration:
Perception:
Intellectual functions:
Memory deficits:
Judgment:
Insight:
Additional comments:
Client strengths and weaknesses
Clientàstrengths:
Clientàweaknesses and obstacles:
Client treatment goals and barriers
Client preferences:
Barriers to achieving client preferences:
Duration:
Additional info:
Summary of presenting problems and recommendations
Summary of presenting problem:
Current and past level of functioning:
Clinical impression:
Justification for issues not addressed in treatment:
Conclusions and recommendations:
(Sample) Treatment Planning Template
Treatment plans are an important part of the helping process. Depending on the type of service and the specific
standards and practices of the setting, treatment plans may vary in content. Treatment plans are used to guide
how services will be delivered. Failure to plan treatment places the worker at risk for fraud, waste, and abuse
and could potentially harm the client. Treatment plans provide documentation that services are rendered.
Client Name: Click or tap here to enter text.
SW Name: Click or tap here to enter text.
Date
Problem Statement (Brief clinical statement of the condition that needs treatment.
Based on assessment data.)
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enter a date.
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enter a date.
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enter a date.
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Goals
(1) Click or tap here to enter text.
(2) Click or tap here to enter text.
(3) Click or tap here to enter text.
Discharge
Objectives (What will the client say or do? Under what circumstances? How often will
Criteria
the client say or do this?)
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enter text.
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enter text.
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enter text.
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Interventions
Target Date
Date Achieved
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enter a date.
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enter a date.
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enter a date.
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enter a date.
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enter a date.
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enter a date.
(What will the SW do to assist the client? Under what circumstances?)
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Client participation in the treatment planning process
Click or tap here to enter text.
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Participation by others in the treatment planning process
Click or tap here to enter text.
Click or tap here to enter text.
Client Signature & Date
SW Signature & Date

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