Family Assessment Questionaire

Family Assessment Questionnaire

To provide you with the best possible service, we need to conduct a comprehensive family assessment. Please answer the following questions as thoroughly as possible:

First name

Last name

Phone

List all relevant family members, their ages, and their roles in the family dynamics from past to present.

Provide a brief overview of each participating family member's relevant history from childhood to the present.

Describe the results you hope to achieve through mediation.

What do you believe each of the other participating family members want to accomplish?

Identify significant familial conflicts or challenges that have led to conflict or estrangement.

Describe each family member's role in these conflicts.

If a single event precipitated the estrangement, please provide details.

How have divorces across generations affected the family?

Detail any significant mental or physical health issues that have affected family relationships.

Describe any challenges related to adoption, LGBTQ+ issues, or gender identity that have impacted the family.

Provide details of all prior attempts to reconcile

Describe the impact of third parties on family dynamics, such as: Other family members and In-laws, Spiritual leaders, & Therapists

If you were advising someone in a similar situation, what advice would you give them about family estrangement?

Where do you envision the estranged relationships being one year from now?

Are you optimistic or pessimistic about the family’s future, and why?

Family Assessment Questionnaire

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