Download - Parent Family Assessment
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CONNECTIONSPARENT -FAMILY ASSESSMENT
PART A: CHILD/YOUTH HISTORY
Child/Youth Name ______
Assessment Date Parent/Guardian Name
Assessment Location Client Home __________ Edison _________ Other __________PRESENTING PROBLEM: Current crisis with child/youth; history, duration, and possible precipitatingevents.
CHILD DEVELOPMENTAL MILESTONES: Comment on prenatal and birth history; infancy issues suchas: toilet training, walking, talking and developmental delays/difficulties; any substance use/abuse at thetime of conception or during the pregnancy.
CHILD/YOUTH MEDICAL HISTORY:
Are childhood immunizations up to date? ____Yes ___NoDate and reason for most recent visit to physician:
Has the child had an eye exam? ___Yes ___NoHas the child had a hearing exam? ___Yes ___No
Any known allergies? ___Yes ___NoIf yes, explain:
Any known medication allergies? ___Yes ___No
If yes, explain: _____________
Indicate Child/Youth Medical History.
Medical Problem
Reference by Name
Time FrameFrom To
Current Status
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CHILD BEHAVIORAL HISTORY: Check appropriate box if behavior has been noticed. (For multiple children, indicate by putting name(s) in appropriate box.
Behavior Denied Past Present Comments: (Frequency, Duration)
1. Loses temper easily/Low frustration tolerance
2. Run Away Behaviors
3. Destructiveness/Vandalism
4. Blames others for own mistakes
5. Frequent Mood Shifts
6. Angry/Resentful/Vindictive
7. Over-Dependent Behaviors
8. Defiant attitude
9. Eating Difficulty/Disorder
10. Initiates fights/Provokes others
11. Physically cruel to others
12. Physically cruel to animals
13. Stealing
14. Lying
15. Sexually Abusive to others
16. Sexually acting out behaviors
17. Arson/Firesetting
18. Truancy
19. Cons other people/ Manipulative
20. Refuses/ignores adult requests
21. Lack of Attention to tasks/Difficulty organizing tasks
22. Hyperactive/Impulsivity
23. Verbal Aggression
24. Problems in School: Academic/Behavioral
25. Homicidal Behavior
26. Sleep Disturbance
27. Withdrawn/Shy
28. Depression/Crying
29. Suicidal Behavior
30. Enuresis: Repeated voiding of urine into bed or clothes
31. Encopresis: Repeated passage of feces inappropriately.
CHILD BEHAVIOR HISTORY: (Continued)
EXPLAIN ALL SIGNIFICANT CONCERNS
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CHILD EDUCATION ISSUES:
Current School:Current Grade Level/Highest Grade Level Completed:
Education Issues: Indicate by number and briefly explain below.
___Academic Achievement Problems ___Child Study Team Evaluation___Speech or Learning Difficulties Date of last Evaluation___Peer Problems Classification
School Behavioral Problems Truancy___School Phobias ___Excessive Absences
Academic performance
CHILD/YOUTH CHARACTERISTICS:
A. Describe his/her personality:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
B. Describe his/her strengths:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
C. Describe areas for improvement:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
D. Describe his/her social interaction with:
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Very Good Good Fair Poor
Mother: ___________________________________________________ Father: ___________________________________________________ Siblings/others in home: ___________________________________________________Peers: ___________________________________________________ Other Adults: ___________________________________________________
CONNECTIONSPARENT -FAMILY ASSESSMENT
PART B: CHILD/YOUTH HISTORY
SAFETY ASSESSMENT: Evaluate family members; familys home and environment by numbering thefollowing safety concerns. Briefly describe any concerns numbered.
___Weapons ___Household Condition ___Domestic Violence ___Pets ___Vermin ___Other Risks
___Neighborhood Condition ___Sleeping Arrangements ___Suicidal Risks ___Homicidal Risks
FAMILY STRUCTURE: Include Parent/Child relationships; status of relationships; domestic violence;marital history; and current custody status.
Family Medication History:
Member Medication TimeFrame
Reason ComplianceY/N
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Family Medical History: List medical issues which have impacted upon family functioning.
Family Member Medical Problem Time Frame
From To
Current Status
FAMILY ADDICTIONS HISTORY: Number all applicable substances/behaviors. Briefly describe itemnumbered including time of onset; family history; types, amounts and time frames of use; physical
symptomatology; (Ie: blackoutsand/or medical problems); indications of tolerance; social, physical &emotionalimpact on family functioning; legal consequences to use; indicate sobriety/relapse history andtreatment history/outcomes.
___Tobacco___Sedatives (Sleeping pills, etc.)
___Caffeine___Inhalants
___Alcohol___Prescription Drugs
___Marijuana ___Non-Prescription Drugs
___Opiates (Heroin, Morphine, Opium, Codeine) ___Gambling___Hallucinogens (LSD, PCP, Acid) ___Eating Disorder___Painkillers (Demerol, etc.) ___Sex___Stimulants (Cocaine, Speed, Crack, etc. ___Excessive Spending___Nicotine ___Not
Applicable
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CULTURAL/SPIRITUAL ASSESSMENT: Describe cultural/ethnic and spiritual/religious backgroundand the impact they have on family functioning and the Mentoring process.
FAMILY BEHAVIOR/SOCIAL SERVICES HISTORY:Include inpatient/outpatient psychiatric and counseling services: detox & rehab services.
FamilyMember
PresentingIssue
Facility/Program
Location Time FrameFrom-To
DischargeDate
For any listed above, please explain familys evaluation of effectiveness and disposition upon discharge.
FAMILY PLACEMENT HISTORY:
Family MemberFacility/Program
Time FrameFrom - To
Disposition Upon Discharge
LEGAL HISTORY: Indicate by check mark and briefly explain about child /family involvement.
___Separation/Divorce ___Police Involvement ___Juvenile ConferenceComm.
Custody/VisitationArrests
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Probation
Guardianship
Incarceration Parole ___Crisis Intervention Unit(FCIU)
___Domestic Violence ___Restraining Order Other
YOUTH DAILY LIVING SKILLS ASSESSMENT: Check the current level of functioning by
indicating the Youths name in the box and comment on problematic areas.
SKILLS BELOWAVERAGE
AVERAGE ABOVEAVERAGE
COMMENTS
1. PersonalHygiene
2. AppropriateDress
3. Meal Prep./Planning
4. House -keeping
5. CommunityResources
CONNECTIONSPART C: SUMMARY OF ASSESSMENTS
SUPPORT/RESOURCE INVENTORY: List and explain all strengths.Family Strengths:
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Family Support Network:
Community Support:
Child/Family Interests & Hobbies:
Recreational Interests:
DESCRIBE FAMILY MOTIVATION TOWARDS CONNECTIONS PROGRAM
EXTRACURRICULAR ACTIVITIES:
1. How does____________ spend time at home?
____________________________________________________________________________________________________________________________________________________________________________________
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____________________________________________________________
2. State interests/favorite activities:
____________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Are activities mostly alone or with others?
____________________________________________________________________________________
4. Describe talents/skills/memberships/clubs.
____________________________________________________________________________________
5. How do you feel about ____________s use of time?
____________________________________________________________________________________
6. What would you like to be different?
____________________________________________________________
________________________________________________________________________________________________________________________
PARENT/GUARDIAN:
Current Family:
1. What is the household like when everyone is together?
_________________________________________________________________________________
2. What problems or concerns exist for the family? (if none, what happens when there is aproblem? How do people respond to each other?)
___________________________________________________________________________________________________________________________________________________________________________
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3. Describe your parenting style:
_________________________________________________________
4. How do you discipline your child (ren):
__________________________________________________________________________________________________________________
5. Is your discipline style the same for each child in the home?
__________________________________________________________________________________________________________________
6. What behaviors in your child (ren) are unacceptable to you:
__________________________________________________________________________________________________________________
7. What types of activities are you involved in outside of the home:
__________________________________________________________________________________________________________________
8. What is current total yearly income? (in thousands)
0.10 30-4010-20 40 +20-30
What do you see the role of the Mentor as entailing __________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
How would you want the Mentor to handle the following situations:
If _________________ misbehaves:
If Mentor and ____________want to lengthen the visit?
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If ________________ wants the Mentor to keep a secret?
If ______________ wont listen to the Mentor?
Additional Comments:
Jeanette Nadonley / Rosi Pena Date
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