Biopsychosocial Case Assessment Format

PART 1

Identifying Information

Name:             Sam Krasniqi

Age:                 Not specified (Most likely middle-aged)

Race:               Albanian/Kosovar

Sex:                 Male

Address:         Residential area is Dallas, Texas

Marital Status:                                   Married

General Physical Appearance:         Not specified in the case.

Referral Information

This is a case that arose after a worried school nurse reported that she saw a daughter from this family named Lima from the Texas Department of Human Services (DHS) being assaulted by the father, the children were then removed from the parent’s care following an investigation. The social worker became aware of the matter in this way.

Reason for Referral/Presenting Problem

The primary reason why the client is seeking services is because of an allegation of sexual abuse where Sam Krasniqi is alleged to have abused his child, Liam. A critical examination shows that this is a case of cultural misunderstandings and conflicting interpretations of parenting practices where the nurse suspected abuse, prompting DHS intervention, leading to parents being denied custody of their children (Uhlich et al., 2021).

Family Relationship Status

Sam’s immediate family is their Wife, Kathy Krasniqi, and two children, Liam and Tim. The age of the children is not specified in the case, even though one can tell from the case that they are minors. The parents and their children were close even though the emerging legal issues have affected that bond. Sam and their wife, Kathy, have fought to retain the custody of their children but have encountered hurdles created by legal representation and cultural perception issues.

Current Family Social Status

Economically, the Krasniqi family operated an automotive repair shop, which provided for their financial needs. However, the legal fees affected the family’s financial resources once the case started. The legal battle has led to a financial constraint on the family.

Background

Krasniqi’s family came from Kosovo, and in the U.S., they were unaware that some of the cultural practices that influenced their parenting styles were considered illegal in the U.S. or would be misunderstood in the country. Their interaction with the U.S. authority was complicated by language. Language barriers and cultural differences further complicate interactions with American authorities (Uhlich et al., 2021). In this case, there is a misunderstanding regarding acceptable and unacceptable behavior within the family structure. Notably, the DHS investigation and the subsequent withdrawal of the children from their parent’s care resulted in trauma, stress, and financial burden.

Family History 

The family came from Kosovo, and through their interaction, one could see that they have close-knit cultural values. In this relationship, there are no previous marriages or divorces noted. However, some significant family events that were recorded were immigration to the U.S. and the ongoing legal issues that have deeply affected the family.

Social History and Connections

This family has strong community support from friends and clients who visited their repair shop for services and many who also testified in the court that their character and family values were close-knit. Family, friends, and community members expressed their disbelief in the charges against Sam and stated that the parents could not abuse their children. The family and friends testified that the parents were dedicated to their children and that their immigration status and limited knowledge of English might have hindered them from fully connecting with formal support systems.

Spiritual/Cultural History and Connections

This family has deep cultural ties to Kosovo, their home of origin. In their case, it is clear that their cultural practices, especially family interactions, are misunderstood in countries like America, especially based on the context, thus leading to the family’s dilemma (Uhlich et al., 2021). Sam and Kathy’s parenting style, as influenced by their Kosovo background, was perceived as harmful by the American authority. In reality, these actions are non-sexual, non-abusive, and appropriate in Kosovo’s culture.

Education History

The case report does not provide any information about the educational background of the father, Sam, or the mother of the children, Kathy. However, the information provided is that this family has challenges understanding the cultural norms of Americans and the legal system of the country, thus making it difficult for them to defend their actions.

Employment/Vocational History (includes Military History)

The report shows that the family survived on income from an automotive repair shop. Even though their financial status was stable, the court case forced the family to use their money on the case to the extent that it led to financial constraints for the family. The legal battle has also consumed their time, which has affected the business and led to further monetary burdens. Therefore, the only thing revealed about employment for this family is that they own the automotive repair shop.

Physical/Medical History

This report only gave the physical examination of the children, and this examination was conducted due to allegations of abuse. The medical examinations from various professionals gave different reports, thus confusing conflicting medical outcomes. The inconsistency in medical opinion further complicated the legal proceedings. On the parents’ side, no medical health information was provided.

Psychiatric and Psychological History

A psychiatrist called Franklin Lewis from North Dallas examined Sam after his parental rights were infringed, and the psychiatrist found that he was not a sexual offender. He also noted that Sam’s behaviour was culturally misunderstood as inappropriate conduct in the U.S., though it was culturally appropriate for this family from Kosovo. The psychological input suggested misconception and not malicious intention from the parent.

Previous Services Received for Related Issues

Based on the report, before this case emerged and the child protective services were involved, Krasniqis had yet to receive any services from social, psychological, physical, or psychiatric professionals. However, when the case started and as it proceeded, these professionals were called in to give their expert opinions on the family. At this point, the family came in contact with the abovementioned professionals.

PART 2

Strengths and Needs of Client

Strengths

1. Strong family bond characterized by parent’s commitment to their children.
2. Cultural resilience with the family maintaining cultural ties.
3. The family has community support from friends and family who showed strong social support.
4. Legal acquittal is another strength because even though the civil judgment was not reversed, Sam was acquitted in criminal court.

Needs

1. Cultural sensitivity and advocacy is needed for the family to navigate misunderstandings and demonstrate parenting behaviors that fit the U.S. context.
2. The family also needs legal support which is considered essential for them to explore options of being with their children.
3. The family also needs mental health services because of the psychological and emotional issues arising from the separation and legal battle.
4. The legal battle has affected the family’s finances therefore they need financial assistant

Professional Impressions and Assessment:

This case presents a complex interplay of legal challenges and cultural misunderstanding. A strong family bond is a strength that offers a foundation for family reunions. The case also presents a situation where parental practices in the U.S. conflict with parental practices in other cultures, thus calling for cultural competence in the U.S. child welfare system.

Key concerns include:

Misunderstanding resulting from cultural differences (Morina & Tribe, 2021)

Emotional trauma resulting from separation

Legal and financial burden due to the legal battle

Case Plan/Goals:

Immediate goals include:

Connecting with culturally sensitive legal aid to help with appeals.

Establishing a mental health service to help the family cope with the trauma.

Connecting with relevant bodies to ensure cultural awareness.

The steps to begin working with a culturally aware attorney are to take a cultural sensitivity course on American parenting and go for an evaluation with the social service (Morina & Tribe, 2021).

Intermediate goals include:

Maintaining communication with the children.

Offering parenting education to the parents to integrate with the norms in the U.S.

Pursuing financial help for the family.

The steps to be taken begin with arranging for a culturally competent mental health doctor, then family and individual therapy, and finally, monitoring emotional progress with the therapist (Uhlich et al., 2021).

Long-term goals include:

Working towards a reunion between parents and children.

Strengthening connections with community organizations for emotional and social support.

Increasing awareness of social services and.

Cultural sensitivity.

Reducing future misunderstandings.

The steps to be taken here begin with consulting with a financial advisor, seeking employment counselling, and reviewing progress.

Signatures and Dates

______________________________________

Your name typed, your title typed

(Signature is normally required. When submitted electronically for this assignment you can type your name)

___________________________________

Date

(Must be dated at the time of your signature.)

Has assessment been reviewed with client? ___yes ____no

___________________________________

Client Signature

(For the purpose of the assignment we will assume you developed your plan and goals with your client. Please also type the client name here in order to correctly complete the assignment.)

__________________________________

Date

(Must be dated at the time of your signature.)

References

Morina, Y. K., & Tribe, R. (2021). The acculturation experiences of first-wave   Kosovan women migrants living in the United Kingdom. Mental Health and Illness Worldwide, 165–186. https://doi.org/10.1007/978-981-10-2366-        8_23

Uhlich, M., Luginbuehl, T. & Schoebi, D. (2021). Cultural diversity within couples:       Risk or chance? A meta‐analytic review of relationship satisfaction. Personal          Relationships 29(3). DOI:10.1111/pere.12405

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PART 1

Identifying Information

Give name, age, race, sex, address, marital status, general physical appearance, including stature/size, and marital status

Referral Information

How did this client come to you or your agency?  Is the client self-referred?  List referring information, if applicable.

Reason for Referral/Presenting Problem

This is the section where you briefly summarize why the client is seeking services.

Family Relationship Status

List the members of the immediate family and briefly discuss the status of their relationships. Names and ages of immediate family members should be included.

Current Family Social Status

Information regarding housing and financial status should be included in this section.

Background

This may be the longest section of the Case Assessment because it contains all pertinent information about the client, family, and environment of the client.  It is the biopsychosocial-spiritual background of the client.

Use the following headings to organize the information in this section.  Enter the pertinent information under the headings in order to be thorough, present quantities of material in an organized manner, to make it easier for you to write, and to make it easier for others to read.

Family History 

Discuss the family of origin in this section. Include relevant information about extended family members. A relevant fact would be, “the father had a significant relationship with his paternal uncle.” Major family life events should be discussed in this section.  Previous marriages and divorces should be included.

Social History and Connections

Information regarding the client and family community support should be included in this section.  Formal and information social groups and organizations that are relevant to the family should be discussed in this section.

Spiritual/Cultural History and Connections

Discuss the client’s past and present spiritual and/or cultural connections.

Education History

Give highest level of education obtained and any significant educational milestones or issues.

Employment/Vocational History (includes Military History)

Give brief employment history with more specific information given about current status.

Physical/Medical History This section should include both a physical developmental history and current health status. Also, include medications, especially medications currently being taken.

Psychiatric and/or Psychological History This section should include any previous or current involvement with psychiatrists, psychologists, or mental health professionals.  For example, “Psychologist, Barbara Nicol, PhD, administered the assessment or test or evaluation Mr. Jones on 2/12/04. Any known recommendations of assessment should be included.

Previous Services received for related issues Services for physical, social, spiritual, psychological/psychiatric concerns, particularly previous services for the presenting issues should be included in this section.

PART 2

Strengths and Needs of Client

Discuss the strengths and the needs of the clients. This can be written in narrative style or can be written as lists.

Professional Impressions and Assessment:

This section involves your critical thinking and assessment skills. There should be NO new information here.

In this section, take the information gathered and give your assessment of the client and the client’s situation. This section should contain what you think are strengths (resources of the client and the client’s environment that can be called upon in addressing the problem or the client reaching goals, etc.), areas of concern or areas for growth, your assessment of the general situation or need and your assessment of the problems to be addressed.  In the medical profession this section would include a “prognosis.”  In social work, we discuss strengths and areas of concern. In doing so, we are stating how probable reaching certain goals will be. In this section, sum up in the Case Assessment and give a professional assessment of the client.

Case Plan/Goals: In this section the worker sets out a plan for addressing the concern or reaching goals. The plan should not be stated in a narrative, but concisely and precisely, preferably in a list:  who, what, when—-who will do what and by what date in order to most likely meet the needs of the client. Referrals should also be included in this section.

What are the goals and what steps will be taken to reach those goals?  They can be separated into categories of long-term and short-term goals. Each goal should include steps (objectives) with projected date for accomplishing the step or objective.

Long-term Goal 1: Things that will likely take months or years.

Include a list of intermediate steps/objectives toward these goals with dates

Short-term Goal 1: Things that can be achieved in a matter of days or weeks.

Include a list of immediate steps toward these goals with dates

Short-term Goal 2: Things that can be achieved in a matter of days or weeks.

Include a list of immediate steps toward these goals with dates

Signatures and Dates

______________________________________

Your name typed, your title typed

(Signature is normally required. When submitted electronically for this assignment you can type your name)

___________________________________

Date

(Must be dated at the time of your signature.)

Has assessment been reviewed with client? ___yes ____no

___________________________________

Client Signature

(For the purpose of the assignment we will assume you developed your plan and goals with your client. Please also type the client name here in order to correctly complete the assignment.)

__________________________________

Date

(Must be dated at the time of your signature.)