Family Assessment Form

Family Assessment

Please fill out the form below so we can assess how best to help your loved one on their recovery journey. Each program is custom tailored to meet their needs, this form is completely confidential in compliance with HIPAA laws. Any information given will not be shared.

This website form will “time out” if it is not submitted in one session. Please give yourself adequate time to complete it in one session.

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Please Note: All information submitted is confidential and processed according to HIPAA Privacy Practices.

Your First Name*

Your Last Name*

Cell Phone*

Email*

Patient's First Name*

Patient's Last Name*

Your Relationship to Patient*

Please Choose a Treatment Facility or Telehealth*

Why do you believe this treatment is necessary?*

How would you describe your perception of the severity of the patient’s problem?*

Mild (occasional)

Moderate (regular)

Severe (daily)

Life Threatening (constant)

How long has it been a problem?*

Less than 1 year

1 to 5 years

5+ years

What steps have been taken to address the above problem?*

What are your expectations of the treatment here?*

What do you believe is the root cause of the patient’s problem?*

Mental Health History

Has the patient been diagnosed with a mental illness?

Yes

Mental Health History

Click the

for additional diagnoses.

Diagnosis

Age of Onset

Treatment and/or Medication Provided

Effectiveness of treatment (1-10), 10 meaning highly effective

Currently Exhibiting Symptoms?

Longest period of sufficient symptom management and dates?

Date Symptom Management Began

Date Symptom Management Ended

What factors contributed to this success?

Activities of Daily Living (ADLs)

Is your loved one able to grocery shop for themselves?

Yes

Is your loved one able to complete basic daily chores (taking out trash, washing dishes, cleaning)?

Yes

Is you loved one able to do laundry?

Yes

Does your loved one shower or bathe at least once daily? If not, how frequently do they shower or bathe?

Yes

If not, how frequently do they shower or bathe?

Does your loved one brush their teeth at least twice daily?

Yes

If not, how frequently do they brush their teeth?

Is there anything additional we should know about your loved one's ability to perform activities of daily living (ADLs) and/or basic self-care?

Eating Disorder History

Has the patient been diagnosed with an eating disorder?

Yes

Eating Disorder History

Click the

for additional diagnoses.

Diagnosis?

Age of Diagnosis?

Longest period of not engaging in eating disorder behaviors and dates?

What factors contributed to this success?

Has the patient ever been in eating disorder treatment?

Yes

What type of Treatment?

When did they experience ED Treatment?

What was helpful about Eating Disorder Treatment?

Was Eating Disorder Treatment Effective?

Yes

What eating disorder behaviors is the patient currently engaging in?

Restricting

Bingeing

Purging

Over-exercising

Laxatives

Diuretics

Diet Pills

Other

None

How has the eating disorder impacted your loved one’s life?

Substance Abuse History

Do you know what substance(s) the patient is abusing?

Yes

Substance Abuse History

Click the

for additional substances.

Substance

Age First Used

Last Use

Pattern of Use

Current?

Longest Period of Abstinence in the Last Year?

Date Abstinence Began

Date Abstinence Ended

What factors contributed to this success?

Process History

Does the patient gamble and/or do you have concerns about the patient's gambling behavior?

Yes

If yes, please describe:

Does the patient play video games and/or do you have concerns about the patient's video game playing behavior?

Yes

If yes, please describe:

How would you describe the patient's usage of their smart phone, TV, computer, tablet, and other electronics?

How would you describe the patient's usage of social media?

Does the patient have a history of sex addiction?

Yes

If yes, please describe:

Does the patient have a history of shopping addiction?

Yes

If yes, please describe:

Wellness History

Does the patient participate in any exercise routine?

Yes

If yes, please describe:

How would you describe the patient's nutrition and eating habits?

How would you describe the patient's sleep habits and pattern?

Power of Attorney/Legal Guardianship Information

Do you or any other person have a Power of Attorney or Legal Guardianship order over the patient?

Yes

Guardian Name(s):

Type of Power of Attorney or Guardianship:

Financial

Medical

Total

History of Risky Behavior

What other risky behaviors (not previously mentioned) has your loved one engaged in?

Psychosocial Information

Does the patient have any specific learning difficulties?

Yes

Has the patient ever been diagnosed with a learning disability?

Yes

Has the patient made a noticeable change in friends over the past several years?

Yes

Has the patient’s leisure and recreational interests changed over the past year?

Yes

Has the patient been fired from any job(s)?

Yes

Does the patient have difficulty keeping a job for a long period of time?

Yes

Has the patient quit a job?

Yes

Has the patient’s attendance at work been affected by use of drugs/alcohol?

Yes

Is the family supportive of treatment for the patient?

Yes

Was the patient adopted?

Yes

At what age did he/she become aware of this?

Is there anything else that you would like to make staff aware of?

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