Social Work Client Clinical Assessment Form
Please complete the Social Work Client Clinical Assessment Form to help us better understand your current situation and support needs. Your responses will inform our assessment process.
Client Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presenting Issue
*
Current Level of Wellbeing
*
1
2
3
4
5
Support System
*
Strong family and friends network
Some supportive relationships
Limited or no support
Other
Daily Functioning Assessment
*
Rows
Independent
Needs Some Assistance
Requires Significant Assistance
Personal Care
1
2
3
Household Tasks
4
5
6
Managing Finances
7
8
9
Transportation
10
11
12
Mood and Emotional State (Past Week)
*
Rows
Never
Rarely
Sometimes
Often
Always
Felt anxious
13
14
15
16
17
Felt sad or low
18
19
20
21
22
Felt hopeful about the future
23
24
25
26
27
Felt overwhelmed
28
29
30
31
32
Client Strengths (Select all that apply)
Resilience
Problem-solving skills
Community involvement
Positive coping strategies
Other
Areas of Challenge (Select all that apply)
Housing instability
Financial stress
Social isolation
Health concerns
Other
Additional Notes or Observations
Submit Assessment
Should be Empty: