Group Assessment FAMILY CASE ASSESSMENT OUTLINE (Terror in the Family) Section I: Demographic Information on the Family A. Adults in the Home: Na

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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

 

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