9.4 INITIAL ASSESSMENT SUMMARY
Referral source, reasons for referral, problems as stated in first interview if different from referral.
This is to include other problems either recognised or unrecognised by the client or family. Details of earlier problems and information about the way in which present problems arose.
Description of each member of the family to include age, occupation, education, health and kind of person, if known.
Description of the life style of the family (neighbourhood, housing, class, financial position, religion).
Description of the kind of relationships members of the family have with each other and how these seem to be affecting client of functioning of the family as a whole.
Physical description of the client looks, physical health, manner of dress, special mannerisms or characteristics. Way of relating to worker, parents, authority, peers.
Current functioning, i.e. how he is managing himself at home, at work and socially, indicating points of difficulty and reasons if known (e.g. low intelligence, difficulty in making relationships, anxiety, etc.). Characteristic modes of defence, if known.
Description of the client's problem. This might include the type of problem in personal, physical and environmental terms.
For example : This is an 80 year old man who is suffering from chronic bronchitis. Since his wife died five years ago he has been living alone in a rapidly deteriorating terrace house, in an area which is due for slum clearance. He is becoming increasingly confused, upsets the neighbours with his language and is not able to look after himself properly. He is reluctant to go into an old people's home.
This would be a description of the work already attempted with the client with comments about the client's response and ability to use a relationship with the worker for practical or/and personal help.
Questions and problems which the worker is struggling with.
Summaries
In addition to the interview summary and the initial diagnostic summary, student should be expected to write periodic summaries, transfer summaries and closing summaries for the official file.