By Nancy Summers Published by Brooks Cole Cengage Learning 2009 Fundamentals of Case Management Practice: Skills for the Human Services, Third Edition Chapter Sixteen Social Histories and Assessment Forms By Nancy Summers Published by Brooks Cole Cengage Learning 2009

WHAT IS A SOCIAL HISTORY A social history is: A description and history of the presenting problem (the problem that brought the client into the agency). Background information on the person’s life. The worker’s impressions and recommendations.

Layout of the social history: the categories to cover Presenting problem Description and history of the presenting problem Background information Family of origin Birth and childhood Marriages and significant relationships Current living arrangements Education Military service Employment history Medical history Legal history Social and recreational interests Religious activities Client successes and strengths Client resources Your assessment Your impressions Your recommendations

HOW TO ASK WHAT YOU NEED TO KNOW It is sometimes difficult for clients to open up to a stranger. Use open questions to soften the interview. All closed questions can sound like a grilling. You will use a few closed questions to get information that you need EXAMPLE: How many days a week do you work? Ask questions with respect and a genuine interest in the client. Example: Tell me about the work you do.

CAPTURING DETAILS Refrain from using vague descriptions or general information. Make the information you put in the social history specific. Look at the history you wrote to see where you would have questions if you were reading it for the first time. EXAMPLE: Poor example: Alice is divorced. Better example: Alice was married in 1992 and was divorced in 2008, following her husband’s incarceration for armed robbery.

SOCIAL HISTORIES IN OTHER SETTINGS When agencies have limited funding to serve the client only a short amount of time a brief social history is necessary. A brief social history has three parts: 1. Presenting problem 2. Background to the presenting problem 3. Your impressions and recommendations Presenting problem - describe why the client is here. Background to the presenting problem - give additional information on the presenting problem, the history of it, and some relevant background information on the client. Impressions and recommendations - write your thoughts about the client and what the client needs.

OTHER WAYS TO TAKE SOCIAL HISTORIES Assessment forms These are used when agencies need a lot of detailed information The form is an outline of what is important. You need to stop and ask open questions as you go through the form. Talk with the client in addition to asking the questions. Taking social histories on the computer: Computers are used so that the history does not have to be typed after you have written it. It is important that you have enough space to write what is important and that you be able to see and fully engage the client.

WRITING IMPRESSIONS AND RECOMMENDATIONS First sentence Begin with the same comprehensive sentence you used to open your social history. EXAMPLE: Marie is a 13 year old girl living with her single mother and currently addicted to crack. Next two or three sentences Write two or three sentences to describe the client’s situation. She is currently not attending school and her mother indicates she cannot manage her at present. The girl’s father is not in the picture and mother works 2 jobs to support the daughter and herself.

WRITING IMPRESSIONS Impressions Next state your impressions. Write about these areas if they are relevant: functioning affect vegetative functions insight motivation to change motivation to accept help EXAMPLE: Marie is somewhat guarded with a flat affect. She shows some insight into her problem and indicated some motivation to change the situation both at home and at school.

WRITING RECOMMENDATIONS Finally write your recommendations and say what they are for. EXAMPLE: Recommend 3 weeks intensive inpatient treatment for detox, followed by NA meetings 90 meetings/ 90 days for support in remaining clean, family and individual counseling to develop better family relationships and Marie’s self-esteem. Recommend Marie return to school at the end of inpatient treatment to maintain her academic achievement.

NOTES ON ASSEMBLING GOOD HISTORIES Category headings on the same page as the information that follows the heading. Bold all your subheadings. Staple the pages of the history together. All social histories must be typed. Social histories should be placed in the same location in every chart or record. Be sure the history indicates “taken by” or “prepared by” with your name and credentials. Don’t state as fact things the client told you but you do not know firsthand. Say, “according to client’ or “the client stated”.