There are several pieces of documentation that were used in the case. They include guidelines for continued treatment with the agency, consent forms, comprehensive assessment, and a performance evaluation tool to measure the effectiveness of the interventions. First is the program rules (appendix A). The program rules include proper conduct while at the out-patient facility, and expected adherence to treatment. Examples of proper conduct are no smoking except in designated areas, and having shoes and shirt on while on site. Other examples involve behavior on premises, which include any act of violence or threats of violence to people or property, carrying a weapon of any kind into the site, and any selling or purchase of illegal drug or any …show more content…
The form allows the client's guardians to decide what information will be released and they can also determine the purpose of the disclosure. For example, information that could be released is treatment plan, psychiatric evaluation, and standard treatment. An example for purpose of the disclosure is coordination of services and of care. The document allows the the client's guardians the flexibility to choose what information is divulged and the limitations of what information is provided with another entity involved with the treatment of care. An example of when the document is important is when coordinating treatment and implementing treatment with the school. In the client's case she is currently struggling with passing the third grade. The guardians of the client can utilize the consent for disclosure of confidential information to communicate to the agency what information if any they want disclosed regarding the …show more content…
The assessment holistic approach to understanding what has occurred and currently occurring in the clients life as well as understanding what is considered a priority of treatment for them and their guardian. The assessment begins with the presenting issues asking what brought the client in. The section also covers when the problem started, how long it has been going on, what is the level of intensity of the problems, and how frequently do they occur. In the family and social history section examples of questions asked are current household member, how does the client get along with others, client's strengths, and who do they go to when they need help. The next section is the abuse and sexual risk behavior where the client is asked if they feel safe inside and or outside there home and if they have or know of anyone that has been abused or neglected. Developmental history is then taken, which includes history of pregnancy, any disorder or disabilities the client has been diagnosed with, and delays in any motor
The assessment process is the back bone to any package of care and it is vital that it is personal and appropriate to the individual concerned. Although studies have found that there is no singular theory or understanding as to what the purpose of assessment is, there are different approaches and forms of assessment carried out in health and social care. These different approaches can sometimes result in different outcomes.
Executed physical holds, as necessary to deescalate the situation to keep a patient from endangerment to themselves or others.
When clients are referred to Family and Youth Services an initial assessment is performed, which includes information on a clients demographics, residential status, income, insurance coverage, mental or medical history, and main reason for seeking service. The process also includes an overview of different areas of need such as shelter, food, safety, and health care.
During an initial assessment an individual’s ability and communication methods are established. This is done when an individual arrives into care. Everyone involved in the care of this service user is made aware of their needs and preferences regarding communication and any changes are recognised during reviews and shared with the team to ensure the individual’s needs are met.
The family assessment is a thorough assessment done by a health care provider. This assessment is the foundation of how health care providers deliver care for a certain member of the family or the family as a whole. This assessment involves exploration of the family structure, development, and function. In addition, the family will express their strengths and barriers, internal and external structure, ethnicity, social class, religion, and subsystems, which will allow the reader a better understanding of the family’s functioning.
Assessment tools are used in the care planning process to build up a holistic picture of an individual’s needs. When all the details have been recorded an assessment can be made and suitable care and support can be identified. A few of the assessment tools are information from the individual such as diaries, observations, medical histories and checklists.
Clinical assessments have their place in almost every facet of the psychological and educational realms. I have been tracking down and examining what the most important aspects of assessment are that come into play in regard to drug and substance abuse, custody battles, as well as the importance the role of adhering to the ethical standards of utilizing culturally informed assessments. Clinical assessments within mental health centers are carry great importance in the identifying underlying behavioral problems, diagnosis, and treatment of patients. Behind every assessment is a clinician who
There are many assessment processes that are used to identify substance abuse as well as many other disorders that are addictive. These processes include the SBIRT, AUDIT (Alcohol Use Disorders Identification Test), NIDAMED, CAGE AID (which is used frequently within the counseling foundation), AUDIT-C, and also the DAST-10 which is an assessment process used to evaluate drug abuse within the patients. These are many different processes that are currently used to identify these addictions in clients. The activity of identifying these processes can be over a period of time or can be evaluated in that same day or after the evaluation is completed.
When monitoring care and progress towards the family’s goals to make available to the family an inform consent form to be able to assess progress of effective goals from other services involved. This would be helpful for readjustment of goals. When monitoring the progress of Jimmy’s behavior, parents would journal Jimmy’s daily actions. They would solicit reports from his school teacher on his participation and disruption in class. Moreover, with the inform consent release I as counselor would communicate with each resource program Jimmy and the family are in. This would give data on what is needed to continue treatment. If Jimmy responding to the services and accomplishment Jimmy has made within the selective time period for review. With the
The needs assessment relates to an individual’s care and personal needs, the assessment centres on the activity for daily living and the
There are currently several, well laid out, initiatives to help children who may be at risk in their homes. Assessments of a home are made in order to guage how safe the environment is, education on why child welfare needs to make assessmentsl, determine the family 's ability to know what adjustments need to be made and ensure an adequate support system is in place. Following home assessments, use of the North Carolina Family Assessment Scale helps to identify the services which are needed the most, measure change in a home and examine safety, children remaining in their own home and well being. This assessment will be used after deciding continued services are necessary and at the point when a case will be closed.
First the case is send to the program from the District Attorney’s Office, and then a letter is send to the child’s home for invitation to the program. When the client comes in I first take a MAYSI assessment (Massachusetts Youth Screening Instrument). After the assessment, I briefly go over the result of the assessment and then conduct an orientation to the family to help them better understand what the program is really about. The family does have a choice whether or not they would do the program. If they decided that the program is a good fit for them then I schedule them for a comprehensive assessment which takes up to two hours to complete. The comprehensive assessment form assess in four major parts which is education history, family history, substance abuse and physical mental health status. After the assessment I then decide which type of intervention approach that I’m going to use. The program does not provide any type of counseling we have to refer out to the community for intervention.
Becoming acquainted with a potential client’s history, personality and present concerns is necessary in forming a foundation for counseling interventions. This information gathering phase is referred to as assessment (Mears, 2010). While some mental health professionals will use an interview as their primary assessment tool, others will utilize testing
The information that must be presented to clients, first and foremost, are their rights and responsibilities as a client working with a particular therapist. Beyond this, an informed consent should outline the goals of the counseling relationship, the responsibilities of the client as well as the therapist, expectations of the client, limitations of the counseling relationships, fees involved, approximately how long the therapy process will take, and background information regarding the therapist, particularly their past experience and educational qualifications (Corey, 2013). Corey also mentions the informed consent process is an ongoing educational experience that lasts the
A psychological assessment is the venture of a capable experts, generally a psychologist, to operate the techniques and tools or materials of psychology to ascertain either common or unique facts about another person, either to notify others how they function now, or estimate their attitude,behavior and functioning in the future. The issue of assessment is generally diagnosis or classification. These are the movement of placing a person in a certainly or loosely characterized category of people. This leads to swiftly grasp what they are similar in general, and to evaluate the existence of other thematic features based upon people similar or likely to them. Case history data, clinical interview, psychological tests and behavioral observations