CONNECTIONS

PARENT - 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 precipitating
events.

CHILD DEVELOPMENTAL MILESTONES: Comment on prenatal and birth history; infancy issues such
as: toilet training, walking, talking and developmental delays/difficulties; any substance use/abuse at the
time of conception or during the pregnancy.

CHILD/YOUTH MEDICAL HISTORY:

Are childhood immunizations up to date?
Date and reason for most recent visit to physician:
Has the child had an eye exam?
Has the child had a hearing exam?
Any known allergies?
If yes, explain:

____Yes

___No

___Yes

___No

___Yes
___Yes

Any known medication allergies?

If yes, explain:

___Yes

___No
___No

___No
_____________

Indicate Child/Youth Medical History.

Medical Problem
Reference by Name

Time Frame
From To

Current Status

CHILD BEHAVIORAL HISTORY: Check appropriate box if behavior has been noticed. (For multiple children, indicate by putting name(s) in appropriate box.
Behavior

Denied

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 Withdrawn/Shy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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Past

Present

Comments: (Frequency, Duration)

CHILD EDUCATION ISSUES:

Current School:
Current Grade Level/Highest Grade Level Completed:
Education Issues: Indicate by number and briefly explain below.
___Academic Achievement Problems
___Speech or Learning Difficulties
___Peer Problems
School Behavioral Problems
___School Phobias

___Child Study Team Evaluation

Date of last Evaluation
Classification
Truancy
___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
Mother:
Father:
Siblings/others in home:
Peers:
Other Adults:

Good

Fair

Poor

___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

CONNECTIONS
PARENT - FAMILY ASSESSMENT
PART B: CHILD/YOUTH HISTORY
SAFETY ASSESSMENT: Evaluate family members; familys home and environment by numbering the
following 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

Time
Frame

Reason

Compliance
Y/N

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 item
numbered including time of onset; family history; types, amounts and time frames of use; physical
symptomatology; (Ie: blackouts and/or medical problems); indications of tolerance; social, physical &
emotional impact on family functioning; legal consequences to use; indicate sobriety/relapse history and
treatment history/outcomes.
___Tobacco
___Sedatives (Sleeping pills, etc.)
___Caffeine
___Inhalants
___Alcohol
___Prescription Drugs
___Marijuana

___NonPrescription Drugs
___Gambling
___Eating Disorder
___Sex
___Excessive Spending

___Opiates (Heroin, Morphine, Opium, Codeine)

___Hallucinogens (LSD, PCP, Acid)
___Painkillers (Demerol, etc.)
___Stimulants (Cocaine, Speed, Crack, etc.
___Nicotine

___Not
Applicable

CULTURAL/SPIRITUAL ASSESSMENT: Describe cultural/ethnic and spiritual/religious background

and 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.
Family
Member

Presenting
Issue

Facility/
Program

Location

Time Frame
From-To

Discharge
Date

For any listed above, please explain familys evaluation of effectiveness and disposition upon discharge.

FAMILY PLACEMENT HISTORY:

Family Member
Facility/Program

Time Frame
From - To

Disposition Upon Discharge

LEGAL HISTORY: Indicate by check mark and briefly explain about child /family involvement.
___Separation/Divorce

___Police Involvement ___Juvenile Conference

Comm.

Custody/Visitation
Arrests
7

Probati
on
Guardia
nship
Incarceration

Parole
(FCIU)
___Restraining Order

___Domestic Violence

___Crisis Intervention Unit

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

BELOW
AVERAGE

AVERAGE

ABOVE
AVERAGE

1. Personal
Hygiene
2. Appropriate
Dress
3. Meal Prep./
Planning
4. House keeping
5. Community
Resources

CONNECTIONS
PART C: SUMMARY OF ASSESSMENTS

SUPPORT/RESOURCE INVENTORY: List and explain all strengths.

Family Strengths:
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COMMENTS

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 a
problem? 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
10-20
20-30

30-40
40 +

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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