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The Social History

#UTMSWRK350 // University of Tennessee at Martin
by

Donald Jordan

on 28 September 2016

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Transcript of The Social History

The
History
Social
Donald G Jordan, LMSW // University of Tennessee at Martin // #UTMSWRK350
what makes up the story of a person?
overall notes on
Proofed
Edited for valid information only
Absence of info notated
Appropriate quotations as often as possible
Always clear who is saying what
Connection with presenting problem
Clear headings
Consistent formatting
Consistent spacing
Consistent labeling
Consistent wording
I. IDENTIFYING INFORMATION
A. Name
B. Address
C. Phone
D. E-Mail
E. Age/Date of Birth
F. Social Security Number
G. Other
1. Race
2. Insurance
3. Employment
4. etc.
H. Emergency Contact Person, Relation, & Info

II. PRESENTING PROBLEM
A. What is the reason for your involvement?
- IN CLIENT'S OWN WORDS
B. History of concern?
1. How long?
2. Symptoms?
C. What is different now?
1. Why did the individual decide to see you?
2. Who decided they would see you?
D. What has been tried in the past to relieve
concern(s)?
E. Other questions you are left with?


III. PREVIOUS TREATMENT OR
AGENCY INVOLVEMENT
B. Past agency/organization involvment
1. Where? When? For how long?
2. Who initiated it? Who did you work with there?
3. Was it successful? Why/why not?
4. Are they willing for you to contact that
provider?
(If so, get a ...)
IV. FAMILY HISTORY

1. Who was in the family?
2. Where did they grow up?
3. What were relationship like within the family
during childhood?
4. How were they disciplined? By whom?
5. How were they supported or encouraged? By
whom?
6. Happiest time? Saddest time?
7. What do they remember that stands out?
8. Current relationship with family of origin?

V. MEDICAL HISTORY*
A. Current Medical Issues
1. Current diagnoses, symptoms, medications
2. Current physical pain? intensity? meds?
3. Recent major surgeries or new diagnoses?
4. Any social/emotional implications?
5. Physician related to issue?
If yes....
9. If members are deceased, how did they die?
Client’s feelings about the loss?
10. Other questions regarding family of origin?

A. Family of Origin
B. Current Family
1. Are they married, single, divorced, dating widowed?
a. How did they meet their significant other?
b. How did families feel regarding the relationship?
c. What are client's feelings/thoughts about it?
2. Any other marriages, divorces or separations?
3. Any children? Where? By whom? Comments?
4. Any other thoughts you are left with?
VI. EDUCATIONAL HISTORY
C. Other questions you are left with?
VII. EMPLOYMENT HISTORY
A. Current Employment
1. Where? Doing what? Feelings about it?
2. Relationships at work? Boss? Coworkers?
3. Is income adequate to meet needs?
VIII. SOCIAL/RELIGIOUS HISTORY
A. Social Support
1. Friends? who? length/nature of friendship?
2. Other clubs, organizations, neighbors, groups?
3. Dating? Significant other? How long? Etc.
IX. LEGAL HISTORY
C. Other questions you are left with?

X. SUBSTANCE USE/ABUSE HISTORY
B. Past substance use and/or abuse
1. Age at first use?
2. What substance? How much? How often?
3. With whom?
4. Cost? How was it paid for?
5. Feelings about use?
6. If discontinued, when? how long? why?
7. Was there a progression of use?
8. Were you ever caught? Any consequences?

C. History of Treatment for Use/Abuse
1. Ever had/been to substance treatment?
2. Where? For what? How long?
3. Was it beneficial? Why/why not?
4. How was the experience for client?
5. Relapse? When? How many?
4. Other treatment episodes?
XI. SEXUAL HISTORY
A. Current sexual activity
1. Sexual preference or orientation
2. Satisfaction/problems with sexual functioning?
3. Birth control? STDs? STIs? Testing?
4. Beliefs or feelings about sex/sexuality
5. Connection to presenting problem?
XII. Activities of Daily Living
B. What happened before the problem, and what is happening now?
1. What tasks have to happen?
2. Are those tasks getting done?
3. Who does them?
a. who pays bills?
b. who cooks?
c. who cares for children?
d. mows yard?
e. makes appointments?
XIII. Emotional/Psychological Functioning?
A. Suicidal or homicidal ideations?
- plan? access to lethal means? Past attempts?
B. Reality check: delusions? hallucinations?
C. Oriented X 4?: Person, Place, Time, & Event
D. Symptoms of depression? Anxiety? etc.
E. Self-esteem? What do they like about
themselves? What would they change?
F. Any major changes they can think of?
G. Miracle question? Three wishes?
H. Other questions you are left with?

XIV. Worker's Impressions
A. What do you think about the information you
have gathered? Patterns? Possible connections
to presenting problem?
B. Observations or Supported Opinions
could include physical descriptors of individual, hygeine, clothing, speech, gate, body language, eye contact, affect, mood, involvement etc.
C. Ideas for additional assessments needed
D. Possible resources or linkages needed
E. Possible approaches to work with client
F. Synthesized understanding of client's "Big Picture" and stressing of main issues, facts, circumstances you percieve to be of most importance, and how this compares with your client

Each heading bolded, including roman numeral and the title of the heading.
Information included under each heading in narrative, paragraph form only (except sections 1 & 5)
Your opinions, interpretations, conclusions, assumptions, hypotheses, or reasons are not allowed
anywhere
other than section: Worker's Impressions
Professional, nonjudgmental, observational, non-value, coloquial, religious language only unless direct client quote in "..."
Write clearly and succinctly, while gathering all useful and potentially useful information
I. IDENTIFYING INFORMATION
II. PRESENTING PROBLEM
III. PREVIOUS TREATMENT/AGENCY INVOLVMENT
IV. FAMILY HISTORY
V. MEDICAL HISTORY
VI. EDUCATIONAL HISTORY
VII. EMPLOYMENT HISTORY
VIII. SOCIAL AND RELIGIOUS HISTORY
IX. LEGAL HISTORY
X. SUBSTANCE USE/ABUSE HISTORY
XI. SEXUAL HISTORY
XII. ACTIVITIES OF DAILY LIVING
XIII. EMOTIONAL/PSYCHOLOGICAL FUNCTIONING
XIV. WORKER'S IMPRESSIONS
The Social History
*only section I and section V can be written in chart- or list- form rather than paragraph form.
B. Past Employment
1. Where? Doing what? Feelings about it?
2. Relationships, time frame, exit details?
C. Future Employment
1. What would the ideal job be?
2. Any desire to change jobs? Retire? Work?
D. If not employed, explain.
1. student, retired, disabled, unemployed
2. SSI? Disability Income? Other income?
A. Current substance use and/or abuse?
1. What substance? How much? How often? 2. With whome?
3. Cost? How was it paid?
4. Do they think they have a problem?
X. Substance Use/Abuse History (continued)
D. Other questions you are left with?
IV. Family History (continued)
A. Are they currently involved with other
agencies or providers?
1. If so, may you contact them?
(we need a...)
2. Are they in the process of seeking
assistance?
C. Other questions you are left with?
*only section I and section V can be written in chart- or list- form rather than paragraph form.
C. General Health
1. Last physical? dental? vision? allergies? etc?
2. Physician related to issue?
If yes....
B. Past Medical Issues
1. What? When? Circumstances? Decisions?
2. Any current medical implications?
3. Any current emotional/social implications?
4. Physician related to issue?
If yes....
A. Past Education
1. Current or highest level completed?
2. Feelings about the school experience?
3. Any barriers? What kind?
4. Grades? Other measures of performance?
5. Favorite areas, subjects, classes?
6. Extra-curricular involvement?
7. Friends, teachers, relationships at school?
B. Future Education
1. Attitude about personal education?
2. Desire/plans to further education? Explain?
3. Barriers regarding these plans?
D. Other questions you are left with?
C. Spiritual/Religious/Moral Issues
1. Does client consider self to be religious? spiritual?
2. Do they view it as helpful? Integral? Other?
3. History of church/temple/mosque attendance?
4. Current status of religious thought/involvement
5. Anything you can't be forgiven for?
6. How do you decide what's right and wrong?
B. Liesure/Recreational Activity
1. What do you do for fun? hobbies? read? watch?
2. Physical activities regularly?
3. Other social interaction?
A. Current Legal Issues
1. When, what happened?
2. Status of the issue?
3. Will the issue/status affect our services
4. Connection to presenting problem?
B. History of Legal Issues
1. Ever been arrested? For what? When? Resolution of case?
2. Ever been to court for anything? For what? When? Resolution?
3. Connection to presenting problem?
D. Other questions you are left with?
C. History of abuse?
1. By whom, when, nature, reported
2. Current state/status
3. Connection to presenting problem?
B. History of sexual activity
1. First sexual activity? Feelings/thoughts/issues?
2. Connection to presenting problem?
D. Other questions you are left with?
C. General details?
1. Housed? Rent or own? Utilities? Access to transportation?
2. Neighborhood? Do they feel safe? Supported?
A. How is the individual functioning at home before and after presenting problem?
1. eating, sleeping, memory, sex, judgment, other responsibilities
Remember...
Include appropriate quotes as often as able, but ALWAYS noting "client states" or "client reports."
DOCUMENTATION
Full transcript