A Guide for Writing Psychosocial Reports

1. A Guide for Writing Psychosocial Reports SW 550 Field Practicum I

2. Rationale Psychosocial reports: • Provide an in-depth view of the client’s life and how the client and others see him or her as functioning • Are used by the courts, hospitals, schools, social service and mental health agencies, and by other professionals to make crucial decisions about peoples’ lives and the direction these lives may take

3. Rationale • Serve as the foundation for providing accurate assessments and effective interventions • Dynamically respond to changes in the client’s life circumstances • Demonstrate accountability for professional services • Provide required documentation for agency personnel, legal and regulatory bodies, and funding sources • Serve as a method to evaluate practice outcomes

4. Analogous terms used: • Social assessment report • Biopsychosocial assessment • Social history • Psychosocial study • Biopsychosocial-spiritual assessment

5. Varied Formats • Formatting of the psychosocial report varies depending on the agency setting and the needs of the clients served • Common elements include multidimensional focus on the interaction of human biological, psychological, and social functioning

6. Pointers Psychosocial reports should be: • Concise • Organized • Objective • Factual • Thorough • Neat

7. Pointers • Use correct syntax, spelling and grammar • Write in the third person singular • Avoid subjective language or obvious personal opinions and biases • Submit report in a timely manner • Safeguard confidentiality • Exclude irrelevant information

8. Pointers • Report should refer to clients by title and last name unless client is a minor • Final report may not be altered after it becomes part of the client’s file, but a re-assessment report or an addendum can be submitted to correct factual errors

9. Multi-Dimensional Client Information Included in Report • Biological dimension • Psychological/emotional dimension • Family dimension • Religious/spiritual dimension • Social/environmental dimension (micro and macro dimensions)

10. Suggested Format Outline: Step One Initial: • Report heading • Date of report • Name of client • Source of referral • Source of information • Reason for referral

11. Guideline QuestionsStep One • Report heading: Name of agency • Name of Client: This should be at the top of the report under Report Heading and usually listed with the last name first. • Date of report: Date report is written • Date of interview: (if different from date report is written)

12. Guideline QuestionsStep One • Source of referral: Who referred the client? Could be self-referred or referent(s) may be listed by occupation with or without specific names (i.e. teacher, neighbor, parent, doctor)

13. Guideline QuestionsStep One • Source of Information: Where and from whom did you obtain information from this interview? The client? The doctor who referred? The relative, friend, neighbor, teacher? The previous case file or chart?

14. Guideline QuestionsStep One • Reason for referral: Be as specific as possible about why the referral was made. This should be brief and concise. You will expand on this under “problem description”.

15. Format Outline: Step Two Background Information: • Client demographics • Behavioral observations of client • Problem description

16. Guideline QuestionsStep Two • Client demographics: What is the age, sex, marital status, and race of the client? What and where is the client’s current living arrangement? With whom is the client currently living? Identify the age and relationship of current family members in the household. How long has client lived in current housing?

17. Guideline QuestionsStep Two • Behavioral observation: Did the client arrive on time for the appointment? Was he or she accompanied by anyone? How was his or her hygiene and physical appearance? Did the client exhibit any behavioral, cognitive, physical, or emotional problems?

18. Guideline QuestionsStep Two • Problem Description: Expand on reasons for referral based on information gathered during the interview.

19. Format Outline: Step Three • Multi-system review: (history and current): biological, psychological, family, religious/spiritual, social/environmental (micro and macro)

20. Guideline QuestionsStep Three • Biological/Developmental/Medical: Does the client and/or immediate family members have any significant physical problems? Inquire about appetite and sleep as disturbances may be indicators of problems such as depression, stress, food insecurity, etc. If relevant, such as with children, inquire about developmental history (Did child meet his developmental milestones appropriately?) Also be sure to inquire about substance use patterns, including tobacco, alcohol (ETOH) and other drugs, both illicit and prescribed. If there is use of substances, document type, frequency, amount and impact on client’s life. Are there problems with access to medical care, medications, and/or health insurance?

21. Guideline QuestionsStep Three • Psychological: Is there any family history of anxiety, mood disorders, thought disorders, or behavior problems? Any psychiatric admissions or outpatient treatment? If there is a positive history of depression, inquire about suicide history.

22. Guideline QuestionsStep Three • Family: (Immediate household members, including relatives and non-relatives, should already have been identified earlier in report.) Does the client have any relatives nearby? What is the nature of significant familial relationships? Is the client involved in other significant relationships? Are there problems related to domestic violence, current or past? Adverse family conditions, such as incarcerations, traumatic events, etc.?

23. Guideline QuestionsStep Three • Spiritual/Religious: What are the client’s current or past religious affiliations or beliefs? How does the client perceive and give meaning to the events of his/her life?

24. Guideline QuestionsStep Three • Social/Environmental: Describe relevant aspects of the client’s local community. What are relevant cultural and socioeconomic factors? Legal issues? Issues related to housing, food, transportation, utilities, telephone? Does the client have adequate resources to meet his/her needs? What are the macro issues that influence the client? What relevant local, state, or national laws apply? Stereotypes or environmental hazards? Available resources?

25. Format Outline:Step Four Assessment: • Concise statement summarizing the significant findings of the report and relevant features of the client’s psychosocial functioning, including problems and strengths • Use of psychiatric classification (DSM IV-TR) may be used but does not replace the psychosocial assessment

26. Guideline QuestionsStep Four • Assessment: What is your impression of the client’s situation? What are the chief problems or concerns? What strengths or resources do you identify? Are there any safety concerns that require attention? How motivated is the client to receive services? What are the chief obstacles? Are there any macro-system issues that can be addressed? What general direction should intervention take?

27. Format Outline:Step Five Plan: • Specify concrete actions to be taken by client(s) and/or social worker • Address the problems and strengths identified in the report • Address immediate needs first

28. Guideline QuestionsStep Five • Plan: Identify your actions, the client’s actions, and your recommendations based on your assessment. Start with the most pressing concern.