Begin by interviewing the person who is seeking services. If possible, interview family members, former case workers, physicians, teachers, and other people who can inform you of your client’s situation.
Keep a record of all sources used for your assessment. In the assessment you will want to record who you interviewed, any incidents you were able to observe, and any documents you consulted. [1] X Research source
Create a safe atmosphere when conducting interviews by explaining the rules of confidentiality to the interviewees. In general, all information obtained in the interview will remain a part of the report and that you will not share the information with people who are not involved with the case. If your client doesn’t trust you, you will not be able to make a clear assessment. To elicit positive responses, focus on finding the strengths of the client. Do not apportion blame. Negotiate with the client over a mutually agreed assessment. [2] X Research source When you encounter resistance, be optimistic so as not to discourage your client. Continue to be polite, punctual, and attentive. Refrain from using jargon. [3] X Research source
Have an assessment form on-hand during your interviews. Assessment forms include specific questions. Using an assessment form will help focus your interview and allow you to take thorough notes. Many facilities have their own assessment forms available for the interview process
Include as much information as possible. Describe the client’s personal appearance, whether or not the client was appropriately dressed for the weather on the day of the interview, the client’s personal hygiene, ability to maintain eye contact, and the client’s mental orientation (awareness of person, place, time and event). Many facilities have standardized forms that direct you to describe specific questions about the client. One example of categories for an assessment include: “presenting problem,” “problem history,” “personal history,” “substance abuse history,” “family history,” “employment and education,” and “summary treatment and recommendations. ”[4] X Trustworthy Source State of Michigan Official website for the State of Michigan Go to source Another example of such categories include: “identifying information,” “referral,” “presenting problem,” “sources of data,” “general description of client,” “family composition and background,” “educational background,” “employment and vocational skills,” “religious involvement,” “ health conditions,” “psychological background,” “social, community, and recreation activities,” “basic life necessities,” “legal concerns,” “client strengths,” “clinical summary,” and “goals and recommendations. ”
It is often best to refrain from using technical diagnoses, like borderline personality disorder. These can offend the client. Furthermore, they are often not as useful as detailed, specific characterizations of the individual in question.
Set specific goals for the client that are time-limited and attainable. If a goal is to stop using drugs, for example, your treatment recommendation should include a referral to a substance abuse program that requires the client attend a set number of meetings and submit to random drug screenings, and a target date for completion of the program.
Compare and contrast the client’s perception of his problems, needs, weaknesses and strengths with the perceptions of other people you interviewed for the assessment. Such a comparison can provide you with a more complete understanding of the client’s goals and treatment needs.
Schedule a follow up meeting with the client after you’ve written and discussed the assessment to review the client’s progress towards completing each goal. Return to the assessment periodically to evaluate the client’s development
