Family Assessment Page 1: Participant Information Date: Participant 1 Name: Social Security No: Date of Birth: Age: Gender: Current Address: City/State/Zip: Phone Number: Citizenship Status: U.S. Citizen Legal Resident Other: Participant 2 Name: Social Security No: Date of Birth: Age: Gender: Current Address: City/State/Zip: Phone Number: Citizenship Status: U.S. Citizen Legal Resident Other: Marital Status: Single Divorced Re-Married Widowed Married Separated Living Together/Unmarried Local Emergency Contact: Name: Relationship to Participant: Phone Number: Page 2: Income and Employment What is your gross monthly income? Source of Income: Employment SSI SSDI Veteran’s Benefits Alimony Child Support Other Do you receive SNAP? Amount: Do you receive WIC? Have you applied for SSDI? How many times? Currently pending? Where: Disability/Reasons: Page 3: Employment and Education Currently employed? Employer: Job Title: Other adult participants seeking employment? Last worked: How long? Why did you leave? Longest job held: Obstacles in getting a job: What type of work? Full Time Part Time Supportive Housing Program Family Assessment Page 4: Health, Mental Health, Substance Abuse Do you currently have any health issues? If yes, please explain below. Have you had any recent hospitalizations? If yes, please explain. Are you currently taking any medications? If yes, please list them. Mental Health Have you been diagnosed with a mental health issue? If yes, what is your diagnosis? Have you ever been hospitalized for mental health issues? If yes, please explain below. When were you hospitalized and at which hospital? Substance Abuse Do you have a substance abuse issue? If yes, what is your drug of choice? When was the last time you used? Have you ever participated in a substance abuse program? If yes, please explain. What was the date and name of the program? Page 5: Criminal History and Children’s History Have you ever been arrested or convicted of a crime? If yes, please explain. Do you have any outstanding warrants? Are you currently on parole or probation? If yes, please explain. Do you have a current or previous case with Child Protective Services (CPS) or Department of Family Services (DFS)? If yes, explain below. When and where was the case? What was the outcome? Children’s History Please list the names and ages of all children, and indicate whether they are currently living with you and if you have custody. Page 6: Children’s Health, Education, Mental Health, and Legal History Do your children receive regular checkups with a physician or medical professional? Are your children up-to-date on their immunizations? Do any of your children appear to have an undiagnosed learning disability? If yes, please describe. Do any of your children have an active IEP or 504 Plan? If yes, please describe. Children’s Mental Health Have any of your children received counseling? If yes, which child, what type of counseling, and why? Have any of your children been hospitalized for emotional problems? If yes, which child, why, and when? Children’s Legal History Do any of your children have a current or past legal issue? If yes, describe any unresolved issues including where and when they happened. If applicable, provide the youth’s name, probation officer’s name and phone number, and the reason. Page 7: Safety, Strengths, Goals, Signature Are you currently at risk of violence from any family member or someone you know? If yes, please explain. Have your children ever been victims of violence? If yes, please explain. Do you currently have a Temporary Protective Order (TPO) in place? If yes, explain. What do you consider to be your personal strengths? What are your personal goals? What are your goals for your family? Are there any services you would like to receive that have not yet been identified? If yes, explain. Signature I hereby certify that the information contained in this assessment is true to the best of my knowledge. Participant’s Signature: Clear Date: Case Manager’s Signature: Clear Date: Notes: Submit
