1 Family Strengths and Concerns Assessment Name:______________________________________ Date:____________ Strength Communication open, plentiful Togetherness family outings, traditions Appreciation express thanks Encouragement providing support Division of Responsibilities clear/equal tasks Flexibility willing to compromise Affection/Love physical expression Community and Family Ties spirituality, extended family Commitment loyalty, responsibility Forgiveness willing to accept mistakes or apologies Needs Some Improvement Needs Much Improvement Shared Interests enjoying activities together Friendship closeness, companionship Security confidence, well being Trust reliance, faith Warmth tenderness, kindness Respect admiration, high opinion 2 Please list 3 strengths apparent in you and/or your family: 1.______________________________________________________________________ 2.______________________________________________________________________ 3.______________________________________________________________________ Please list the 3 most important issues you would like to discuss throughout the course of therapy: 1.______________________________________________________________________ 2.______________________________________________________________________ 3.______________________________________________________________________ Please indicate if any of the follow issues currently pertain to you: Minor Personal Feelings Major Concern Concern depressed mood/feeling blue feeling less pleasure in activities loss of energy/fatigue insomnia Sleeping too much feelings of guilt feelings of worthlessness significant weight loss or gain thoughts of suicide thoughts of death difficulty concentrating fluctuations in appetite low self-esteem loneliness rejection under eating fear of gaining weight binge eating vomiting meals use of laxatives/diuretics other: ____________________ Not a Concern 3 Sexual Concerns Major Concern avoiding sexual contact absence of desire/arousal sexual abuse history Minor Concern Not a Concern Females: lubrication difficulties problems achieving orgasm recurrent pain during intercourse other: ____________________ Males: delay/absence of orgasm erectile difficulties premature ejaculation recurrent pain during intercourse other:____________________ Substance Abuse Concerns Major Concern excessive alcohol use amphetamines(diet pills,speed) marijuana use cocaine use hallucinogen(LSD, MDMA) inhalant use (gas,glue,paint) nicotine use opiod(morphine, heroin, codeine) use of multiple substances sedative/antianxiety substances legal problems:substance use failure to fulfill obligations social problems quitting substance use other:____________________ Minor Concern Not a Concern 4 Family Roles Major Concern single parenting problems disagreements:housework role arguments (who does what) stepparent and children parental responsibilities other:______________________ Child Concerns Major Concern siblings not getting along new addition to family stealing truancy running away bed or pants wetting/soiling breaking rules wrong group of friends suspicion of alcohol/drug use academic performance problems suicide sexual behavior adjustment (divorce, school,etc.) disability legal problems obesity dating involvement with child protective services child custody proceedings foster care ADD/ADHD anxiety depression suicide loss problems with peers bullying other:______________________ Minor Concern Not a Concern Minor Concern Not a Concern 5 Life Transitions Major Concern divorce separation remarriage remarriage with children moving parenting a new child new job creating a partnership change in religion abortion miscarriage dissolving a partnership creating/integrating a LGTB family other:______________________ Mood Concerns Major Concern Anxiety problems in social situations problems at work uncontrollable worrying Restlessness Irritability muscle tension difficulty concentrating panic attacks unreasonable fear of object unreasonable fear of situation avoidance of social situations repetitive behaviors stress due to traumatic event grief/mourning due to loss other:______________________ Minor Concern Not a Concern Minor Concern Not a Concern 6 Anger Concerns Major Concern difficulty controlling temper excessive anger problems with conflict controlling breaking objects to relieve anger excessive hostility other:______________________ Relational Concerns Major Concern Minor Concern Not a Concern Minor Concern Not a Concern Parent/Child poor communication lack of trust lack of togetherness difficulty adjusting to new rules other:______________________ Partner emotional abuse physical abuse sexual abuse verbal abuse different perspectives clashing poor communication lack of trust disagree about raising kids differences in personality infidelity jealousy intellectual differences emotional intimacy affairs pornography lack of shared interests Major Concern Minor Concern Not a Concern 7 managing past intimate relationships Other: Sibling constant fighting arguing jealousy lack of trust lack of communication refusal to interact other:______________________ Major Concern Minor Concern Not a Concern Family Concerns Major Concern physical problems/illness child custody conditions lack of commitment lack of togetherness poor communication finances extended family disability aging parents other:______________________ Minor Concern Not a Concern Partner Violence Concerns Major Concern slapping hitting pushing excessive and severe arguments threats isolation controlling partners degradation forced distress use of weapons Minor Concern Not a Concern 8 other:________________________ Lesbian, Gay, Bisexual, and Transgender (LGBT) Concerns Minor Concern Not a Concern Major Concern sexual orientation gender identity coming out to others one partner more out than other parental acceptance of identity please specify: connecting to LGBT community religion/spirituality heterosexism/homonegativity/ homophobia other: Family Religious or Spiritual Issues Major Concern family religious differences spiritual or religious practices moral convictions problems stemming from religious backgrounds other: Minor Concern Not a Concern Is there anything marked above that you do not want discussed with other family members? YES NO If so, which items do you not want to discuss? Taken from Stepnowski, B. (2007). Family Strengths and Concerns Assessment. In Hecker, L & Sori, C.F., The therapist’s notebook II: More homework, handouts & activities for use in psychotherapy. New York: Haworth Press.
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