FORMAT : SOCIAL CASE STUDY REPORT DRUG REHABILITATION CENTER
I. Identifying information
II. Presenting Problem
III. Current Situation
IV. Background History
V. Analysis
VI. Recommendations/Treatment Plan
I. Identifying Information
• Demographic information: age, sex, ethnic group, current employment/ household
roles, marital status, etc.
• Referral information: referral source (self or another), reason for referral
• Data sources: interviews with identified persons (dates and persons), examinations
and tests performed, other data used
II. Presenting Problem
• Detailed description: problem, situation, symptoms,
precipitating factor, current feelings and thoughts of the client, how he has
coped so far; best to use the client’s words
• People involved:manner of involvement, perceptions of the
problem, reactions to the problem, how they have contributed to the
problem or solution
• Past experiences:experiences similar to the current difficulty,
manner they were handled and their consequences then
• Other Recent Problems: stressful life events that have
happened in the last year, manner they were managed, the meaning of
these to the client
III. Current Situation
1. Describe family or household
identify the members of the household (names, ages), and relationship (natural child,
stepparent, sister), quality of relationships, distribution of roles
2. Social network: extended family, friends, peer groups, etc
3. Guardian information: if applicable
4. Economic situation: identify those working, nature of employment, adequacy
of income. Identify economic needs, and money management practices
5. Physical environment/ housing: nature of living circumstance and the
neighborhood
6. Significant issues, roles, or activities: i.e., student, retired public or private
employee, health problem, handicapped, legal problems etc
.
IV. Background History
1. Developmental History
2. Family Background
3. Marital/intimate Relationship
History
4. Education and/or Vocational
Training
5. Employment History
7. Use and Abuse of alcohol or drugs
by self and family
8. Health Issues
9. Previous Mental Health
10.Cultural Background
IV. Analysis
1. Identify key issue or problem: compare your perspective & client’s own perspective
of his problem; describe seriousness of the problem
2. Describe client functioning effectiveness
3. Identify contributing factors: thoughts, behaviors, personality issues, and
circumstances that seem to contribute to the problem; determine where factors reside
4. Identify the strengths: sources of meaning, coping ability, and resources that can
be mobilized to help the client
5. Identify stressors: obstacles, vulnerabilities, and needs
6. Assess client’s motivation and potential to benefit from
intervention