Strengths Based Needs Assessment - inspiraforms.com

Strengths Based Needs Assessment Social Supports/Family/Friends: Family makeup i.e. siblings/birth order, what was it like growing up in your family?...

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Strengths Based Needs Assessment Participant Name:

Date:

Introduction: Ask the client, “What brings you here?” Explain what Case Management is. Explain that this assessment process is to establish Goals and Objectives Case Management services. *History; Current; Desired:

Daily Structures/Activities of Daily Living: Current living arrangements? Cooking? Diet/nutrition? Have enough food each month? Transportation? Laundry? Able to purchase the hygiene products you like to use? Appropriate clothing for the season? *History; Current; Desired

Financial/Insurance/Legal Issues (probation, fines, etx.) Current income? Interested or have you applied for SSI? SSDI? Medical Insurance? Have any fines/bills that you are having difficulty paying? *History; Current; Desired

Educational/Vocational: Educational/vocational history? What did you enjoy most? Interested in working/volunteering/going back to school? Military service? Assistance with clothing or other special needs? *History; Current; Desired

Strengths Based Needs Assessment Social Supports/Family/Friends: Family makeup i.e. siblings/birth order, what was it like growing up in your family? Do you prefer to be alone or around others? Do you have someone in your life that you can call when you need something? Do you have or desire as significant person relationship? *History; Current; Desired

Mental Health, Substance Abuse, and/or Addiction Disorders: What brings you here? Take Medications? Interested in talking to the psychiatrist about symptoms & starting/changing medications? Smoke? Interested in stopping? Do you or someone in your family feel you have a problem with SA or another addiction? *History; Current; Desired

G. Health/Medical: Current doctor/dentist? Last time you saw a medical doctor; current medications; any health issues? Allergies? Need any assistance with medical needs at home/work? Last physical/dental check-up? Well woman, mammogram, prostate? Children that need well child, immunizations? *History; Current; Desired

Cultural/Spiritual Beliefs: Family’s nationality/ethnic origin? Where did you grow up? Language you speak at home? Special holidays or traditions? Any certain beliefs about receiving mental health/medical services? Religious preference? *History; Current; Desired

Strengths Based Needs Assessment Wellness/Leisure: What is wellness to you? What do you do in your spare time? What did you used to like to do? Special interest/Hobbies? Activities you currently participate in or would like to get back to? *History; Current; Desired

Overall goals/hopes/dreams: Past accomplishments/activities that made you feel good about the direction your life was going? What will it look like when you don’t need me anymore? *History; Current; Desired

CASEMANAGEMENT INTERPRETIVE SUMMARY: This interpretive summary: Write a narrative paragraph. Include the integration and interpretation of the strength based assessment, and any referral or treatment team information collected. The summary must reflect the participants perception of his/her needs, strengths, life problems, and motivation/commitment to resolve the listed needs and concerns.

Client’s Identified Needs; Identified Case Management/Therapy Services Needed:

Client Signature

Date

Clinician Signature/Credentials

Date