1. Client Identifying Information: Date of interview(s), age, gender, ethnicity, religion, marital status, and referral
    source, etc. Caution: Remember confidentiality: Do not use the client’s real name and disguise any other
    identifying information.
  2. Source of Data: Identify all sources of client information. (e.g., the individual client, family members, data
    from charts, schools or other agencies).
  3. Description and development of the presenting problem: Include the reason for social work involvement at
    this time. What was the precipitating event that brought the client to seek help at this time? Describe in depth
    the current client situation.
  4. Family History: Include chronological history of family and relevant extended family, and brief descriptive
    information about family members. Include a genogram if possible.
  5. Client History:
    a. Include chronological developmental history including all major events from prenatal to present.
    b. Medical and psychiatric history

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