Client's Full Name:
Date of birth:
Type of Disability, if any:
Date when disability or unemployment began:
Date of this assessment:
Mobility:
Need for assistive aids:
Medical History (Hospitalizations, surgeries, other types of care):
Present Health Status:
General Health Status:
Social History
Street Address, City, State, ZIP:
Telephone & email:
Elevator:
yes /
no.
Elevator door width:
Family Members:
Caregiver:
Social Activities:
Hobbies:
Friends outside the home:
The assessment will help to understand the person better. Although young people may have not had the opportunity to attend school, they occupy their time in some way. Perhaps there is a way to help him/her to do some other activity.
Education
Grade completed in school:
Favorite subject:
Favorite school activity:
University or technical school:
Other training or interests:
Work History
Dates and Names of Employers
Job duties:
Favorite job(s):
Leisure activity
How is leisure time spent?
What is favorite leisure activity?
Problem/Goal 1
Plan 1
Problem/Goal 2
Plan 2
I want to be restored to wholeness, and therefore I am ready to change my lifestyle.
Signature: I, , agree to follow the plan.
For those who want spiritual as well as disability/employment counseling, use the spiritual assessment below that will help to better understand people you talk to in churches, hospitals, and other places. Using this approach, you may understand what the person thinks about God and his position with God and then have a basis for further dialogue and spiritual counseling. Otherwise, scroll down to the end to SEND this form.
Spiritual Assessment Tool
1. Everyone thinks about God in his own way. How do you describe God?
2. How do you think God feels about you?
3. Is there anything that helps you know God better?
a. Spiritual doctrines
b. Connection with a church
c. Prayer
d. Scripture/Devotional readings
e. Family or friends
f. Meditation
g. Faith rituals/sacraments
h. Sacred space (church building, cathedral, nature)
i. Clergy
j. Music
k. Radio programs
l. Comments
4. Is there anything that stands between you and God?
a. Conflict in belief system
b. Feels punished
c. Disconnection/conflict with family or friends
d. Loneliness
e. Difficulty praying
f. Anger toward
h. Loss of meaning of life
h. Fear of
k. Feels abandoned by God
l. Guilt or shame
m. Need for forgiveness
n. Fear of dying
o. Grieving
p. Body Image is not normal
5. If you were not concerned about being a bother or a burden, is there anything you wish that someone would help you with or do for you to feel closer to God and other people?
6. If you could ask for anything that would put your heart at peace, what would you ask for?
7. Evaluation of Spiritual Care - Interventions by the Clergy:
a. Listening, empathy and feedback
b. Assist with search for meaning
c. Explore grief/loss issues
d. Explore spiritual issues
a. Facilitate reconciliation
f. Prayer / Sacraments
g. Provide emotional support
h. Facilitate and verbalize feelings
i. Consult with other professionals
j. Comments:
8. Goals of the Spiritual Visit:
a. Verbalize feelings related to spiritual distress
b. Verbalize reduced anxiety
c. Begin to find meaning in present situation
d. Verbalize concerns about death and dying
e. Verbalize sense of hope
f. Verbalize positive statements about self or life
g. Allow pastor or other spiritual helper to provide emotional support
h. Verbalize your building or maintaining a personal relationship with God.
9. Spiritual Resources Provided:
a. Prayer
b. Emotional Support
c. Referral to a pastor/priest
d. Baptism
e. Communion
f. Anointing with oil
g. Reading of scripture
10. Plan for Visitation:
a. Continue to visit
b. Refer to
d. No further visits needed
e. Comments:
Now you can click on the "Send" button below, Then you can copy-and-paste this information from your email program into your client's computer file. Or you can go to the top of this form and print it, then file the paper copy.