Download - Parent Family Assessment

7/30/2019 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 Withdrawn/Shy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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