storage.googleapis.com · web viewauthor healthservices created date 05/11/2015 09:22:00 last...

A Touch of Peace Family # ______________

A Touch of Peace Counseling Services

Home Assessment ApplicationJohn Ruffin, LPC

www.atouchofpeace.org 256-334-9527

Date of Application:_____________

Primary Caregiver: _________________________

Names and birthday of all family members living in the home

(please print)

Name Birthdate Name Birthdate Name Birthdate



Home Address

Street Address: ________________________________________________

City: __________________ State: _______ Zip: ______________

Emergency Contact (Non-resident preferred)

Name: ________________________ Relationship to family: _______________________

Contact number: Cell________________ Home ________________ other _____________

1 A Touch of Peace Counseling Services 5/11/15

Copyright 2015. All rights reserved A Touch of Peace Counseling Services home assessment application.docx


Family Concerns:

________________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

_________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Continue:




Parental Dynamics

Please list parents involved with the guidance of the home

Name Relationship/Role Name Relationship/Role


Other adults: (those that are 18 years of age and older living in the home)


Family members outside of the home that are involved with care (ex. separated parent, grandparents, etc…)






Dependent Information

Name Age

Daily Schedule:

Monday Tuesday Wednesday Thursday Friday

6am

7am

8am

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm



1


8pm

9pm

Talents / Hobbies

______________________________________________________________________________

______________________________________________________________________________

Strengths (things they can contribute to the home)

____________________________________________________________________________

____________________________________________________________________________

Weakness (problems they have that will make them unsuccessful in life)

____________________________________________________________________________

____________________________________________________________________________

Goal (what you would like to see accomplished)

____________________________________________________________________________

____________________________________________________________________________

Medical History

Family doctor: _______________________




Medical Concerns: ___________________________________________________________

___________________________________________________________________________

Medications: ___________________________ _________________________________

______________________________________ _________________________________

Hospitalizations: _________________________________ Date____________

_________________________________ Date____________

Psychological History

Psychiatrist/ therapist/facility: _________________________ Date___________

_________________________ Date___________

Diagnoses: _________________________ Date___________

_________________________ Date___________

Medications: ___________________________ _________________________________

______________________________________ _________________________________


_________________________________ Date____________




Name Age

Daily Schedule:


6am

7am

8am

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

8pm

9pm



2


Talents / Hobbies

______________________________________________________________________________

______________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________

Medical History

Family doctor: _______________________


___________________________________________________________________________8 A Touch of Peace Counseling Services

5/11/15



Medications: ___________________________ _________________________________

______________________________________ _________________________________


_________________________________ Date____________



_________________________ Date___________

Diagnoses: _________________________ Date___________

_________________________ Date___________

Medications: ___________________________ _________________________________

______________________________________ _________________________________


_________________________________ Date____________




Name Age

Daily Schedule:


6am

7am

8am

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

8pm

9pm



3


Talents / Hobbies

______________________________________________________________________________

______________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________

Medical History

Family doctor: _______________________



5/11/15



Medications: ___________________________ _________________________________

______________________________________ _________________________________


_________________________________ Date____________



_________________________ Date___________

Diagnoses: _________________________ Date___________

_________________________ Date___________

Medications: ___________________________ _________________________________

______________________________________ _________________________________


_________________________________ Date____________




Name Age

Daily Schedule:


6am

7am

8am

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

6pm

7pm

8pm

9pm



4


Talents / Hobbies

______________________________________________________________________________

______________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________

Medical History

Family doctor: _______________________



5/11/15



Medications: ___________________________ _________________________________

______________________________________ _________________________________


_________________________________ Date____________



_________________________ Date___________

Diagnoses: _________________________ Date___________

_________________________ Date___________

Medications: ___________________________ _________________________________

______________________________________ _________________________________


_________________________________ Date____________




A Touch of Peace

Program Disclaimer / Family Counseling Rights / Confidentially

Program Disclaimer

The Home Manager will be using the Maturation Therapy© model when developing an environment that will promote positive interaction, growth in maturity, healthy connections and build an over-all happy experience for members of the home. Even though, this program uses specific techniques that have been prove to help in the growth and cohesiveness of the environment, it is up to those that are involved to cooperate with the process. It is not the Home Manager’s job to disciple or parent in any kind of way. Our job is to provide tools that the family can use to build the best environment possible for positive growth amongst its members.

Family Counseling Rights

The following are rights that every member of the family group shares. These rights are designed to maximize growth amongst the group and insure that all parties are aware of the expectations. These rights are to help foster unrestrained growth in family cohesiveness:

Members have a right to know: Any member of the specified group can be made aware of the recommendations made by the Home Manager.

Members have the right to feel protected: Each member of the group or their guardian has signed the statement of confidentiality and therefor agrees to protect the information discover during the family sessions.

Members have the right not to participate: each member’s participation in the program is voluntary. Any member of the group can state that they don’t want to participate. (Even though you have this right, the cancelation of services can only be done by the one who initiated services or head of home.

Members have the right to not be harmed: Services can be terminated if Home Manager determines that the services are doing more harm than good.




Limits of Confidentiality

Service providers within A Touch of Peace Counseling Services strive to insure the confidentiality of the information disclosed by their patients. In most cases, when patient care information needs to be disclosed, the patient’s permission is obtained before disclosure. There are, however, a few uncommon circumstances when disclosure can occur without the patient’s prior consent. These include disclosure as permitted by the Federal Privacy Act, by law, by regulation, by judicial proceeding, and by standards of ethical professional practice. The following are typical but not exhaustive examples of situations and circumstances under with information may be disclosed without prior consent.

1. If a provider believes you intend to harm yourself or someone else, it may be the duty of that provider to disclose that information for the protection of the endangered person(s).

2. In situations of suspected child abuse, it is the duty of the provider to notify medical, legal, or other authorities.

3. If you are involved in legal action/proceedings, your records may be subject to subpoena or lawful directive from a court.

4. Qualified persons may be permitted access to your record as part of professional quality assurance review procedures. Any information from the patient’s record subsequently disclosed by the review conceals the identity of the patient.

Statement of Understanding I have read the above and understand the information about me will be safeguarded within the limits of confidentiality outlined above and in the Privacy Act Statement.

All those age 12 and up must sign the above agreement to participate(Print, Sign, and Date)

Print Name Sign Date


















Therapist Signature I understand that each member that sign must understand the above Limits of Confidentiality




storage.googleapis.com · web viewauthor healthservices created date 05/11/2015 09:22:00 last...

Documents