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Sample Family Assessment Form

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Sample Family Assessment Form
 
(Excerpted from The ACCESS Mentor Training Manual. Used with permission from the Mentor Coordinator Network, Grand Rapids, Michigan.)
 
Family
 
1. Father:                                                                Date of Birth:
2. Mother:                                                               Date of Birth:
3. Children:                                                              Date of Birth:         
                                                                             Date of Birth:                           
                                                                              Date of Birth:
                                                                              Date of Birth:
4. Marital Status:                                                         Anniversary:
5:  Telephone:
6. Present Address:
 
7. How long have you lived at your present address?
          Previous address:                                                                 How long?
          Previous address:                                                                 How long?
          Previous address:                                                                 How long?
 
Education
 
1.  List highest education and other training/skills.
 
2. List children or family members that are currently in school (name of school and grade).
 
Leisure Activities
 
1. What are your hobbies or interests?  Include interests of all family members.
 
Medical/Emotional
 
1. Do you or any member of your family have any medical issues?
 
2. Do you have any medical insurance?    Yes     No    Coverage:
 
3. Are you or anyone in your family currently on any regular medication?
 
4. Do you or any family members currently struggle with a substance abuse problem?  Yes     No
Comments:
5. Have you or any family members struggled with any substance abuse in the past? 
Yes     No
Comments:
6. Are you currently receiving or have you ever received any type of counseling? 
Yes     No
If yes, please comment:
 
Transportation
 
1. Do you have an automobile?     Yes               No
2. Make/Model/Year
3. Condition:
4. If no car, what is your main method of transportation?
5. Do you have auto insurance?     Yes               No
6. Is your driver’s license valid?    Yes               No
 
Legal Circumstances
 
1. Have you or any of your family members ever been convicted of a crime?  Yes           No
Name/Circumstance/Year:
 
2. Are you or any member of your family currently on probation?         Yes             No
If yes—who, for what and how long?
3. Have you or any members of your household been involved with Protective Services?
Yes               No                If yes, please explain:
 
Employment History- Current to Previous
 
1. Present Employer:
Address:
City:                                                               State:                     Zip:
Supervisor’s Name:                                                    Phone:
Employment Status:  FT               PT                 Temp            Permanent
Employed from                            to
Job Description:
 
2. Previous Employer:
Address:
City:                                                               State:                     Zip:
Supervisor’s Name:                                                    Phone:
Employment Status:  FT               PT                 Temp            Permanent
Employed from                            to
Job Description:
Reason for Leaving:
 
3. Previous Employer:
Address:
City:                                                               State:                     Zip:
Supervisor’s Name:                                                    Phone:
Employment Status:  FT               PT                 Temp            Permanent
Employed from                            to
Job Description:
Reason for Leaving:
Other sources of income (please list):
Religious Background and Preference
 
Other Support and Assistance
 
1. List any assistance you have received or are currently receiving from family, friends, agencies or churches/congregations:
Date             Name of Organization                                       Type of Assistance/Amount $
 
Family Support, Friends, and Emergency Contact
 
Please list 3 individuals who have known you for at least one year.
Name:
Address:
Telephone:                                                      Relationship:
 
Name:
Address:
Telephone:                                                      Relationship:
 
Name:
Address:
Telephone:                                                      Relationship:
 
Name:
Address:
Telephone:                                                      Relationship:
 
 
Family Strengths
 
1.
2.
3.
4.
5.
Family List of Needs/Goals in Priority Order
1.
2.
3.
4.
5.
Acknowledgement/Release of Information
The above information is true and complete to the best of my knowledge.  I give the staff of [name of your program] permission to verify all information given in this document.  I understand that the information provided in this interview is confidential and will not be shared outside of  [name of your program] staff without my prior knowledge and consent.  I further understand that the information will be used as a means to help me create a plan of action to begin working on my goals and objectives related to my current situation.  This permission is good for 12 months from the date of my signature below or until I choose to retract it, whichever is sooner.
Signature of Family Member:               
Signature of Family Member:
Date:
I give the staff of [name of your program] permission to share information given in this interview with a local church as necessary to arrange a Family Support relationship for my family and me.  Name of church:
Signature of Family Member:
Signature of Family Member:
Date:
Family Support Counselor:                                                    Date:
 

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