Holistic Assessment Mental Health Services

Transcription

1 Holistic Assessment Mental Health Services Name: Worker(s) completing assessment Sources used to complete assessment (e.g., client, social worker, psychiatrist, family member, workers from another agency etc.): Date Commenced: Date Completed: 1

2 SOCIAL HISTORY Name of Client: SOCIAL HISTORY Consider: Family background, place in family, siblings, early childhood experiences, education, adolescence, family relationships, adult relationships, (e.g. marriage, divorce, children, friends), employment, stressful life events (SLE s), mental and physical ill health, housing history. History and diagnosis 2

3 HOUSING HISTORY/OFFENDING HISTORY HOUSING HISTORY Consider: Previous housing history including, accommodation and tenancy type, landlords, previous addresses. Reasons for previous placements/housing breaking down, other housing related problems e.g. evictions, arrears, neighbour disputes, overcrowding, abandonment s, harassment. Any periods of homelessness, use of homelessness services. OFFENDING HISTORY Consider: Any history of previous offences, offending behaviour, correction, custodial sentences, probation orders, use of forensic services (inc special hospitals/regional Secure Units), relevant sections of MHA, use of Offender services including aftercare services. 3

4 1. MENTAL HEALTH 1. MENTAL HEALTH Consider: History, diagnosis, symtomatology, current management, pattern of previous illnesses, risk factors/behaviours, previous hospital admissions, users preferences in event of crisis/acute onset, stress factors, prevention of crisis, self esteem, needs for counselling, therapy, other treatment, self help etc. Drug/alcohol/substance abuse history, any current problems/needs, management, any behavioural problems and current management. Note: Medication form should be completed in detail. History and Diagnosis: Strengths/Abilities Problems/Needs 4

5 2. RISK FACTORS 2. RISK FACTORS Strengths/Abilities: Consider: Self harm, harm to others, abusive relationships, vulnerability to exploitation, physical safety, orientation, confusion, risk of homelessness, family breakdown, loss of relationships, possible breakdown of support arrangements, risks associated with drug/alcohol/solvent abuse, child protection issues. 5

6 3. PHYSICAL HEALTH 3. PHYSICAL HEALTH Consider: Any physical health problems? Physical disabilities? Difficulties with sight, hearing, speech, and mobility. Need for assessment/treatment? Aids/adaptations? Maintenance of health: Adequacy of diet/fluid intake, nutrition, and relaxation. Monitoring, e.g. well women/men, smear tests, eye and dental checks, other tests. Chiropody needed? Registered with GP? Other primary health care input needed? Any needs for general health information, advice, counselling? Strengths/Abilities: 6

7 4. SELF CARE 4. SELF CARE Strengths/Abilities: Consider: Dressing, washing, bathing, shaving, personal hygiene, appearance, adequacy of clothing etc. Need for aids/assistance? Scope for further independence? 7

8 5. DAILY LIVING SKILLS 5. DAILY LIVING SKILLS Strength s/abilities: Consider: Needs and abilities regarding the following shopping, cooking, cleaning, washing clothes, household management, nutrition, scope for rehabilitation/further independence? Need for aids, adaptations, equipment, and assistance? Support Needs: 8

9 6. HOUSING 6. HOUSING Strengths/Abilities: Consider: Appropriateness, general condition, outstanding repairs, furniture adequate?, adaptation needed?. Overcrowding, neighbours, any difficulties in maintaining housing/tenancies etc. 9

10 7. MONEY 7. MONEY Consider: Management of finances, budgeting, payment of bills, debts, level of income, benefits, need for welfare rights advice, is there an appointee if so who? Court of protection? Need for supervision? Scope for further independence/rehabilitation? Is income being maximised? Strengths/Abilities: 10

11 8. OCCUPATION 8. OCCUPATION Consider: Work (paid/unpaid)/training/education etc., opportunities for meaningful activity/socially valued roles? Unmet needs? Need for advice, information, counselling in these areas? Strengths/Abilities: 11

12 9. LEISURE 9. LEISURE Strength s/abilities: Consider: How does person spend their time? Leisure opportunities? Culturally appropriate? Have they got interests? Do they need information on activities in their locality? Would they need someone to accompany them? 12

13 10. RELATIONSHIPS 10. RELATIONSHIPS Strength s/abilities: Consider: Social contacts, networks, opportunities for making friends, meeting people and socialisation any needs/problems? Need for befriending? Issues/needs around sexuality? 13

14 11. FAMILY/CARERS 11. FAMILY/CARERS Consider: Contact with family members/significant others. Nature and degree of contact. Family relationship difficulties? Any informal carers? If so, any unmet needs for support, respite, advice/information etc? (Key contacts should be recorded on information sheets check upto-date) Strengths/Abilities: 14

15 12. CULTURAL/SPIRITUAL/RACE/GENDER/SEXUALITY 12. CULTURAL/SPIRITUAL/RACE Strengths/Abilities: GENDER/SEXUALITY Consider: Has the person got access to culturally appropriate services, facilities, and social/leisure opportunities? Religious/spiritual needs met? Record any unmet needs in these areas. Any needs/problems around race, gender (e.g. harassment, discrimination)? 15

16 13. INFORMATION/ADVOCACY 13. INFORMATION/ADVOCACY Needs: Consider: General need for information/advice/counselling/ advocacy/representation 16

17 15. ASPIRATIONS/CHANGES 14. ASPIRATIONS/CHANGES Aspiration/Changes: Consider: General need for information/advice/counselling/advocacy/ representation Needs: 17

18 OTHER INFORMATION Other Information 18

19 ASSESSMENT SUMMARY & RECOMMENDATIONS ASSESSMENT SUMMARY & RECOMMENDATIONS Name of Client: Strength s/abilities: Risk Factors: Recommendations: Web form 19