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RUNNING HEADER: Bio-Psychosocial Assessment

Bio-Psychosocial Assessment
Caitlin A. DeMara
Wayne State University

Bio-Psychosocial Assessment Part

Part A
Presenting Problem: Rena Shore is an 18 year old adopted daughter to Nancy and Charley
Shore, who also have a 12 year old biological son named Michael. Rena currently lives on her
own, but even early off in her life tried to separate herself from the rest of her family. Rena
presents abandonment, trust, and commitment issues paired with her familys myriad of personal
issues that have turned into problems to be dealt with by one another. Problems that Charley and
Nancy have were enough to push Rena out of their environment whenever she was given the
opportunity.

Bio-Psychosocial Assessment Part

Family of Origin History: At Renas adoption (at six months old), Nancy was 25 years old and
Charley was 33 years old. They had been married for five years at the time of the adoption.
Charleys low sperm count and Nancys irregular ovulation made fertilization nearly impossible.
After four years of failure to become pregnant, the couple decided to adopt.
Nancy is currently 43 years old and Charley is currently 51 years old. While Rena was growing
up, she recalls incidences that made her upset and have stuck with her throughout her entire life.
Often, she was shut down and reprimanded for things that truly made her happy, which in turn,
turned her off to such things, and now she has problems completing tasks and goals once she
begins them.
Developmental History: Due to the fact that Rena was adopted a few months after birth, we do
not have information regarding the length of pregnancy at birth, birth weight, issues present at
birth, vaginal delivery or C-section, biological family health history or issues, etc. We do know
that Renas birth mother also did not get along with her parents while she was in high school and
that she also dropped out of high school before graduation. Renas birth mother also had
problems with picking the wrong boys in terms of relationships. Rena lives her life in a pattern
of gaining and dropping meaning she starts something new, and somehow, whether it be
through excuses or actual crisis, she quits whatever it is and doesnt go back, until she vows to
do better and creates the entire process all over again.
Health History: Since Rena was adopted, there is no extensive health history in regards to her
case.

Bio-Psychosocial Assessment Part

Relationship/Sexual History: Rena states that she picks boyfriends that are worse off than
herself. She does not have friends because she pushes them so much until she leaves, and then
blames them instead of herself in the end.
Family of Creation History: At this time Rena has no stable relationship with another person,
has not been married, and has no children nor has she said anything about her being pregnant at
any time in her life or having an abortion.
Substance Abuse/Abuse History: So far, there has been no mention of Rena abusing any type
of substance, nor a familial history of such a think with her biological mother.
The only relation to this within the family can be seen in Nancys chain smoking.
Mental Health History: Rena wishes to go to therapy, search and find her birth mother, and
attends meetings of adoptees, birth mothers, and adoptive mothers. She is not currently in
therapy because there is a waitlist for outpatient services at the community health mental clinic,
and her case is at the bottom of the list. She strives for personal growth and wants to deal with
the parts of her past that have hurt her. She has spent a lot of her life thinking that without a
crisis, she does not know how to live, so she creates problems. She often hides behind problems
she creates in order to get out of situations, i.e. doing well in college, getting a boyfriend,
dropping out, and then blaming it on him.
Military History: N/A
Financial History: Renas adoptive parents have struggled with making ends meet in their lives.
Nancy and Charley both had incidences of being out of work and having a hard time paying all

Bio-Psychosocial Assessment Part

of their bills. Rena does not even have a dollar to her name and has student loans to pay off as
well. She has no job and her bank account is overdrawn.
Legal History: N/A
Immigration Issues: N/A
Clients Strengths: Rena shows great strength in different aspects of creativity. From a young
age, she was able to strongly sing, act, create, and work mechanically on projects. Rena has great
passion when she gets excited about something, this strength would grow even more if she had
the proper support behind her passions and the parts of her life she wishes to accomplish. Rena
already journals and thinks introspectively about her current life, past life, and what she wants
for herself in the future.
Part B
Plan of change: The Generalist Intervention Model
1. Work with the client
a. As a social worker, I will provide a safe, open, and supportive environment for
Rena to explore her past experiences and feel okay to ask questions, talk about her
past, and about her dreams for the future. It is important for Rena to identify her
own problems and what is most important for her in the moment. I will take a
strengths based approach to ensure she is empowered and able to make her own,
well-thought out decisions.
2. Prioritize problems (Problem Statement)
a. Rena is a client that struggles with her own identity, self-determination,
commitment, and trust. I will develop these ideas with Rena and see if she brings

Bio-Psychosocial Assessment Part

these things into the open on her own or if she has other ideas of what the
problems are. We must take a holistic approach to each problem and identify all
aspects that need addressing.
3. Translate problems into needs (developing a goal for the identified change)
a. The goal for Rena is to develop a healthy, stable, and supportive living
arrangement and network of people, hobbies, and activities to support her goals
and help her move forward. Suitable language and realistic planning will take
place.
Lack of healthy, stable, and supportive living arrangement: need for housing that
is affordable, safe, and in a place that condones health and support rather than the
opposite.
Lack of hobbies: need for Rena to commit to a project or life decision. The follow
through will not only empower Rena, but show her that she is capable of the
dreams she has been dismissing her entire life.
Suitable language and realistic planning: need to not sugarcoat the situation or
talk above Renas understanding.
4. Evaluate levels of intervention for each need
a. Needs:
i. The ability to pay for housing: job, realistic living arrangement, ability for
long term stay and stability. Create savings in order to pay off student
loans and have financial cushion for incidentals and emergencies.

Bio-Psychosocial Assessment Part

ii. Support system: job with supportive coworkers and opportunities,


counseling with family and intervention of past cyclical behaviors and
outcomes.
5.7.
Establish goals/Specify Objectives/Specify Action Steps
I.
Goal Number One: Maintain paid for housing and basic needs-clothing, food, etc.
a. Objective Number One: Find a suitable and manageable job.
i. Task Number One: Create an up-to-date resume focuses on strengths and
abilities.
ii. Task Number Two: Seek out employment through filling out applications,
dropping off resumes, networking with pre-existing relationships and
resources.
b. Objective Number Two: Maintain employment and work on commitment issues
to projects and jobs. (leading up to monetary stability because of the commitment
to a job)
i. Task Number One: create some type of reward for each week of
attendance at job.
ii. Task Number Two: create bigger rewards for six months employed, one
II.

year employed, promotions, recognitions, etc.


Goal Number Two: Self-determination
a. Objective Number One: Find activities and hobbies to fulfill need for self-identity
and self-confidence.
i. Task Number One: Look into community resources for free art classes,
free theatre productions to see or be involved in, etc.
ii. Task Number Two: Commit to one type of activity and go to the first
meeting.
b. Objective Number Two: Understanding personal feelings and expression
i. Task Number One: Take journal writing to the next level and create a
doodle/art journal to go along with the written entries Rena is already
partaking in.

Bio-Psychosocial Assessment Part

ii. Task Number Two: Build confidence to bring these journals to sessions
and go over them in the sessions. Come to sessions prepared to share at
III.

least one thing in the safe space.


Goal Number Three: Understanding the Family
a. Objective Number One: Repair the Family Unit (If this is something wanted and
agreed upon by the client and other people involved in the family unit)
i. Task Number One: Find out what family members are willing to meet and
talk about their past and their ideas and needs for the future.
ii. Task Number Two: Use journal to focus on relationships with family.
Possibly get to the point where the family can come to sessions and certain
entries, ideas, and thoughts can be addressed to try and repair and regain
the family unit in the healthiest way possible.

8. Create a contract (omitted from paper per Professors instruction)

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