Social Isolation

 

Instructions: Fill out this form, print it, and hand it in with your assessment to your instructor. When you click on Next at the bottom of the page, you see the data you submitted. Please follow the instructions on how to save the data on the next page.

AOL users: Read this instruction.

Definition:state in which an individual feels a need for contact with others but is unable to make that contact. Aloneness that is perceived as imposed by others and as a negative or threatened state

1. Your initials (required): 

2. Defining Characteristics- check those that apply to your client:

None- high risk diagnosis  expressed feelings of aloneness absence of supportive significant others (family, friends)
expressed feelings of rejection inability to meet expectations of others sad, dull affect  uncommunicative
3. Related Factors- check those that apply to your client:

alterations in appearance alterations in health status treatment imposed isolation (communicable diseases for example)
inability to engage in personal relationships inadequate personal resources unacceptable social behavior
psychologic impairment hospitalization  no means of transportation situational (divorce, death of loved one)
extreme poverty


4. Goal (ultimate, long term) 

5. Outcome Criteria (short term) 


6. Evaluation: Was the outcome criteria met? 

Yes- Give Evidence: 

No- Explain how you would change the plan: 

7A. Interventions 

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7B. Rationale for each intervention
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