1. Identifying Information
Client system demographics (i.e. race, age, gender, work environment (if applicable), living environment, location of residence, etc.)
2. Presenting Concerns/Issues
What is the concern/issue identified for the focus of the interaction between the client system and social worker? How does the client system perceive his/her situation/concerns? What does the situation mean to him/her? Identify concerns/issues in order of priority from highest to lowest from the perspective of the client system and from the perspective of others significant in the client system experience.
3. Background of the Concerns/Issues
How did the situation come to be as it is? How long has it been occurring?
What has been done up to the point of the interaction between the client system and social worker to manage the concerns/issues? What is the intensity of the concern/issue? What stressors are emerging as a result of the concern/issue or are contributing to the concern/issue? What intrapersonal, interpersonal, and/or contextual factors and forces are
impacting the situation?
4. History
Provide relevant medical/health/physical; psychiatric; education; economic, employment; family dynamics; experience of physical, sexual, and/or emotional abuse; spiritual; and/or developmental history.
5. Current Functioning/Mental Status
Appearance: dress, posture, body movement; Speech: speed, volume, pattern, tone; Emotional Adjustment: affect, mood, stability/volatility; Thought Process/Cognitive Functioning: content, perception, associations, comprehension, judgment, reasoning; Sensory Perceptions: hearing, sight, hallucinations; Mental Capacities: orientation to person, place, time, concentration, memory, intelligence; Attitude
6. Family/Economic/Social/Spiritual/Cultural Situation
Create an ecomap of the client system’s current relationships and interactions. Describe the contents of the ecomap.
7. Coping Mechanisms/Resourcefulness
Identify general client system strengths and the functional strengths that are associated with each of the general strengths
8. Goal Development
Who and/or what is the focus of the planned change effort? What are the client system’s desired outcomes/goals? [The wording of the goals reflects the principles of clarity, specificity, measurability, reality, legality, and positivity.] How will/might progress toward and/or achievement of the desired outcomes/goals be measured?
9. Motivation
Identify the direction and strength of the motivation for and commitment to addressing the presenting concerns/issues and achieving desired outcomes/goals.
10. Conclusions/Summary
Briefly summarize the evidence [factual data and observations] and develop hypotheses that reflect alternative explanations of the situation. Relate the hypotheses to theory.
11. Plan Development
What alternative(s) exist for managing the concerns/issues and achieving the desired outcomes/goals? What alternative(s) is (are) recommended? What intervention strategies will be employed to achieve desired outcomes? Identify evidence that supports the recommended interventions. What actions by whom and when will be necessary to achieve desired outcomes? What challenges [real, perceived or potential obstacles] to achieving the desired outcomes might be present? What can be done to manage or avert the challenges?)
12. Ethical/Value Dimensions
Identify and discuss the ethical and value issues involved in this situation.
13. Write a summary of the content, process, and outcome of your experience over the semester with your elder.
Reflect on the meaning of this experience for both you and your elder. What changes have you observed in your elder? How has this experience impacted your elder and you? What have you learned? How will what you have learned affect your practice as a generalist social worker?