Family Assessment Information Form

Family Assessment Information Form
Your Information
First Name:*
Last Name:*
Relationship to Patient:*
Phone:*
Email:*
Preferred Method of Contact:
Patient Information
Full Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Patient Address:*

Street Address

Address Line 2

CityState/Province/Region

Zip/Postal CodeCountry
Patient Phone:*
Patient Email:*
Medical & Mental Health History
Known Allergies:*
Current Health Issues:*
Special Dietary Needs:
Disordered Eating History:
History of Hospitalizations or Recent Surgeries:
If yes, if follow-up care required?

YesNo
Substance Use History:*
Last Known Substance Use:*
History of Overdose:
Psychiatric & Treatment History
Past Treatment and Psychiatric History:*
Current Prescribed Medications:*
History of Suicidal or Homicidal Ideation/Attempts:*
Legal and Social History
Any Current or Past Legal Issues:*
Who Does the Patient Currently Live With?*
Family History & Trauma
Describe Any History of Addiction, Compulsivity, Abuse, and/or Rigidity in the Family of Origin:
Known Trauma History (physical, sexual, emotional):
Treatment Goals & Concerns
What Are Some Significant Issues You Would Like to See Your Loved One Address in Treatment?
Additional Comments or Concerns:
Please verify that you are human*
Should be Empty:

Your Information