Hypothetical Working Agreement

Freydia's Working Agreement

Scenario

Freydia is a 27-year-old mother who has been using crack cocaine for 4 years. Her children, ages 7 and 9, have been removed from her care by Child Protective Services and are currently living with her mother. Freydia comes to the drug program saying: "I want to get my children back."

Client Assessment

Client Name ___________________ Freyda Somebody________________________________

Address _______123 Somewhere Street_____________________________________________

City ___________Someplace________________ State __MH__ Zip Code____12345________

Social Security Number ___123___-___45__-___6789___Date of Birth___12/23/80________

County_________Here_________________________________________

_________________

Home Phone (___123_____) - ________456__________ - ____7890_____________________

Cellular Phone (___234_____) - _______567___________ - ________9012________________

Gender: [ ] Male Race: [ ] African American

[ X ] Female [ ] Asian

[ ] Caucasian

[ ] Hispanic

[X ] Other __________Undecided_____________________

Relationship Status: [ X ] Single

[ ] Married

[ ] Divorced

[ ] In a relationship

[ ] Widowed

Employer ____A fun place to be___________________________________________________

Address ____________Pretty Close________________________________________________

City ______________Hometown_____________ State __MH__ Zip Code_______43785____

Work Phone (_____547___) - _______986___________ - _______________3245___________

Religious Affiliation_______None______________________________________

____________

Sexual Identity___________Straight_________________________________

_____________

Education: [ X ] Grade School Education

[ ] High School Education

[ ] GED

[ ] College Education

[ ] Certificate

[ ] Associates

[ ] Bachelors

[ ] Masters

[ ] PhD

Any other Educational Training ______None_________________________________________

Significant Other Name _______Not Applicable_____________________________________

Address ____________________________________________________________

__________

City _____________________________________State _______Zip Code_________________

Home Phone (___________) - _____________________ - _____________________________

Cellular Phone (___________) - _____________________ - ____________________________

Mother Name ______Mommy Dearest______________________________________________

Address ______566 Inahouse____________________________________________________

_

City