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 Withdrawn/Shy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 everyon