Based on the following:
Diane is a 15-year-old, Caucasian female. She is a freshman at a new high school where she began 3 weeks into the semester. Her current residence is the homeless shelter in a local church. Diane’s teachers felt she was having difficulty adjusting to the new school because she sat with her head down and was very quiet, so they referred her to me. I am a school social worker, part of the child study team, and I regularly do social assessments on students to evaluate how they are functioning from a biopsychosocial perspective.
Upon first meeting with Diane, I noticed that her clothes were wrinkled and her hair seemed as if it had not been washed in some time. Eager to develop rapport, I introduced myself and explained my role at the school. Diane was quiet, with her eyes downcast and provided one-word answers to my questions. When I realized I was not building rapport, I gently asked how she was feeling, and she replied, “Awful.” I asked what was causing this feeling and she began to cry and inventoried what was upsetting her. She told me it was too difficult for her to shower at the shelter as there was a limited amount of time and some people took too long. She also reported that she felt so embarrassed about her appearance, she didn’t have any friends, she was lost in her classes, and her mother cried all the time. She explained that she had seen her mother abused many times, and they finally escaped and found “this church to help us.”
I was grateful that she opened up and realized that there were many issues to address. Recognizing that some of these were basic needs, I decided to first tackle her physiological needs to provide some relief, and then later I would address some of the other concerns, such as safety, her sense of belonging, and academic issues.
After learning Diane did not have lunch due to a lack of money, I got her some food from the cafeteria, and we began to develop a plan together. We drew a large circle and placed her name in the circle along with all the presenting problems she had named. We began with physiological needs. I gave her information about the free lunch program, explaining to her that other students would not know she was enrolled in it because she would have a cafeteria swipe card identical to everyone else’s. I also said that I would try to coordinate for her to shower in the girl’s locker room after school. This, however, would require interacting with other entities such as the shelter, school administration, and, of course, her mother. We drew circles around the large circle so I could show her all the interactions that needed to take place. We decided to check things off as we made progress. We set up weekly meetings for the next month to address and fine-tune these issues.
As the month progressed, Diane was coming to our meetings much more relaxed. She was enrolled in the free lunch program and was showering after gym class during her study hall. Once her physiological needs were being met, I noticed that her grades began to improve. I felt we could begin to address some of her social and emotional needs, such as developing friendships and healing from the abuse she witnessed.
Diane expressed interest in painting, and I mentioned the after-school art club that worked in the school studio and went to museums and galleries. Diane was interested in attending, and I thought that this was a good place for meeting potential friends. When I gently broached the subject about counseling, Diane became anxious. I gave her the hotline number and the location for the local domestic violence agency and told her that they offered free counseling services and had creative arts therapies, which would allow her to use her painting as an expression for her healing. I encouraged her to connect with the agency to see what it was like and to see the art therapy room.
Diane stops by my office less frequently now. Recently she informed me that after 6 months of counseling at the agency I recommended, she feels excited and empowered to make a difference for others. She signed up for the volunteer training at the domestic violence agency, and she wants to paint murals in the art therapy room. She recruited a friend from the art club to join in the training.
- Presenting issue (including referral source)
- Demographic information
- Current living situation
- Birth and developmental history
- School and social relationships
- Family members and relationships
- Health and medical issues (including psychological and psychiatric functioning, substance abuse)
- Spiritual development
- Social, community, and recreational activities
- Client strengths, capacities, and resources
I struggle with bio psycho social assessments and don’t have much experience apparently in has to be professional language
I just need a brief summary at the end of the assessment.