How to Write an Assessment for Social Work

Gathering information

Schedule interviews. Most of the information that a social worker incorporates into a social work assessment comes from direct reports from all parties involved with a case. 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.

Review documents. You can add to your information by consulting important documents. These might include psychiatric, educational, vocational or medical tests as well as agency records. 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.

Interview clients in a safe atmosphere. The most important part of the assessment process is creating a rapport with your client and other interviewees that would encourage them to divulge information honestly. Focus on obtaining information about the client’s needs and the resources that would help fulfill those needs. 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. When you encounter resistance, be optimistic so as not to discourage your client. Continue to be polite, punctual, and attentive. Refrain from using jargon.

Ask open-ended questions. These require the person to respond with detailed answers. Questions requiring only a yes or no answer will not produce enough information for you to write an assessment that can be used to set goals and determine a treatment plan. For example, instead of asking if the client is angry with another individual, ask them to explain how they feel about them. 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

Writing the Assessment

Recognize the flexibility of the writing process. There is not necessarily a single way to write an assessment. This can cause trepidation because you will need to find your own voice, but it does allow you to write the report as you think is best for your particular case. 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.” 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.”

Ascertain the problem. The most basic function of the assessment is to determine what the social worker is trying to accomplish with the client. Reports are often written in a narrative form that tells the story of the client's current problems and how and when those problems initially appeared. It is important to do this in a way that would not offend the client. 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.

Find strengths and solutions. You should make an effort to ascertain the strengths and resources of the client, as well as the community that he is part of. Think about how these can be used to improve the client’s condition. 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.

Think about the client “ecologically.” Remember that the client is influenced by a wider social “ecology” that includes his family, school, workplace, the community, and the wider sociocultural context. Consider how this contributes to the client’s needs or how the resources of individuals in this wider context can contribute to rectifying problems. 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.

Use the assessment as part of the therapeutic process. Use the occasion of writing the assessment to think comprehensively about how to improve the client’s situation. Share a summary of the assessment with the client. This can encourage him to reevaluate his situation and might help him reach his own conclusions about how to precede. Try to negotiate a consensus rather than unilaterally imposing your own assessment. 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