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:
