This Online Assessment can take five to ten minutes to complete. Our organization is HIPAA Compliant. Your privacy and comfort in working with our organization is one of our highest values. Please complete to the best of your ability so that we can match you with the appropriate team of professionals.

    Patient Information

    Preferred Contact Method:

    What are preferred days and time to be able to communicate with your custodial-ally? Please provide information about what days of the week, time of day, etc. would be preferable. Please include times and days of the week that will not work.

    Employment Status

    Employment Type:

    Income Level:

    Emergency Contact Information

    Health/Medical Information

    Do you have a Primary Care Physician? Can you provide their name and contact information?
    Do you have any medical conditions that affect your familial relationships? Are you on any medications?
    Do you or have you engaged a counselor or therapist for personal or family matters?

    Personal/Family History Questions

    How well are you doing with your family relationships (Immediate, external, etc)?
    Does anyone in your family have a history of mental illness? Substance abuse?
    Do you have personal goals? Have you written them down? Are you willing to share them with your therapist/counselor?
    Are you generally positive about your future outcomes?
    Would you like to be able to communicate better with your custodial-ally?
    Was communication plentiful when you were married or co-habitating?
    Are you content with your life where you are currently? If not, what would you like to change? (Personally, professionally, financially, etc)?
    Do parents and leaders have the same responsibility, respectively?
    How much time do you spend one-on-one with your child/each of your children?
    Does your family have structure from mother and father to the children?
    What do you think can be improved?
    What would the child(ren) say about their parents ability to parent them?