Describe sources of information used to collect assessment

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Reference no: EM133605941

Case Study: Background information: The client is a 35-year-old undocumented Hispanic male construction worker who had spinal fusion surgery after suffering a severe back injury on the job. The patient is seeking treatment at the Rehabilitation hospital to regain the ability to walk, personal hygiene, and return back to work. He lacks health insurance, speaks little English, and relies on his undocumented wife for translation. Despite living in a low-income neighborhood with two U.S. citizen children, he identifies as Catholic and routinely attends church with his family. Presenting Problem: Following surgery, the client experienced persistent pain, mobility difficulties, and emotional discomfort. He voiced concern about his rehabilitation, capacity to work, ability to pay for his family, and legal predicament. His legal predicament created challenges with ICE initially. He also described himself as miserable, despairing, and disconnected from his social support network. His notion includes a wish to return to everyday life as soon as possible. Intake: A comprehensive biopsychosocial intake assessment was performed by the social worker, which included medical history, symptoms, medication, family background, immigration status, employment, income, housing, education, language, cultural beliefs, religious affiliation, social support, coping strategies, goals, expectations, and service needs. Standardized pain, depression, anxiety, and substance use screening instruments were used. The goal was to collect complete data for evidence-based treatment planning. Engagement: The social worker communicated with the client and his wife courteously and empathically, explaining the aim and scope of services, getting informed consent, and assuring confidentiality. Using translators, identifying and supporting the client's cultural identity, being sensitive to immigration status, and including religious views in the treatment plan were all examples of culturally responsive skills. Active listening, open-ended questions, reflection, summary, validation, normalization, and empowerment strategies were essential.

Questions: 1. Assessment: Describe the process of assessment and the major findings/needs from the assessment including:

  1. Describe sources of information used to collect assessment data (interview, collaterals, etc.)?
  2. Describe the theory(ies) that drive the assessment.
  3. How do different systems (family, school, work, etc) impact the client's experience of the problem?
  4. What resources and strengths are available in the client's life (family, social supports, community services, etc.)?
  5. How was the assessment completed from a cultural diversity and responsiveness lens?
  6. What ethical questions or considerations emerged?
  7. How did assessment lead to the identification of goals and the selection of interventions?

Reference no: EM133605941

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