FAMILY CASE ASSESSMENT OUTLINE
(Terror in the Family)
|
Section I: Demographic Information on the Family |
A. Adults in the Home:
Name Age Status
B. Provide a brief description of each individual in the home
|
Section II: Presenting Problem and Background Information |
A. Provide a brief description of the presenting problem
B. Background Information
1) Recent Background (recent life changes, precipitating events, first symptoms, stressors, etc.):
2) Related Historical Background (family history, related issues, past abuse, trauma, previous counseling, medical/mental health history, etc.)
|
Section III: Systemic Assessment |
A. Client/Relational Strengths (Each Family Member)
1) Personal/Individual
2) Relational/Social
3) Spiritual
B. Family Structure and Interaction Pattern
1) Couple Boundaries [ ] Clear [ ] Enmeshed [ ] Disengaged [ ] Other __________
Rules for closeness/distance:
2) Couple Problem Interaction Pattern
Start of tension:
Conflict/symptom escalation:
Return to “normal” /homeostasis:
3) Couple Complementary Patterns [ ] Pursuer/distance [ ] Over/under functioner
[ ] Emotional/logical [ ]Good/bad parent [ ] Other _________________________
4) Communication Styles
Adult Male: [ ] Congruent [ ] Placator [ ] Blamer [ ] Superreasonable [ ] Irrelevant
Adult Female [ ] Congruent [ ] Placator [ ] Blamer [ ] Superreasonable [ ] Irrelevant
Describe Communication Dynamic:
C. Family Structure and Interaction Pattern
1) Family Life Cycle Stage:
[ ] Single adult [ ] Marriage [ ] Family with young chn. [ ] Family with adolescent chn.
[ ] Launching children [ ] family with young adult chn. [ ] Mid-life [ ] Later life
Describe struggles with mastering developmental tasks in one of these stages:
2) Hierarchy Between Child/Parents
Father: [ ] Effective [ ] Insufficient (permissive) [ ] Excessive (authoritarian) [ ] Inconsistent
Mother: [ ] Effective [ ] Insufficient (permissive) [ ] Excessive (authoritarian) [ ] Inconsistent
Describe and/or give examples
3) Emotional Boundaries with Children
Father: [ ] Clear/balanced [ ] Enmeshed (reactive) [ ] Disengaged (disinterested
[ ] Other __________________________________
Mother: [ ] Clear/balanced [ ] Enmeshed (reactive) [ ] Disengaged (disinterested
[ ] Other __________________________________
Describe and/or give examples
4) Triangles/Coalitions
Father and __________ against ___________
Describe:
Mother and __________ against ___________
Describe:
D. Intergenerational Patterns
1) Substance/alcohol abuse [ ] N/A [ ] Hx ___________________________________________________________________________
2) Sexual/physical/emotional abuse [ ] N/A [ ] Hx
___________________________________________________________________________
3) Physical/mental disorders [ ] N/A [ ] Hx
___________________________________________________________________________
4) Historical incidents of presenting problem:
5) Family Strengths
6) Previous Solutions and Unique Outcomes
a) Solutions that DIDN’T work
b) Solutions that DID work
7) Dominant Discourses and Diversity (dominant discourses informing definition of problem[s] for example cultural, ethnic, gender, sex orientation, etc., other social influences)
5
