Family Assessment Tool

Name of interviewer: _______________________________________

Date of assessment: ___ ___ / ___ ___ /  ___ ___ ___ ___

Patient’s First Name: _________________________   MI: ______  Last Name:______________________________

County: _______________________________________

Family Member’s First Name: _________________________   Last Name:______________________________

Address: ________________________________________________Phone Number: ________________

Relationship to Patient: ­__________

Does Patient Speak English? _______ If not, what is Primary Language? _________________________

 

Please read to the family member:

 

My name is ______________________________________, and I am also a family member of a mental health consumer.  I am working with the _____________________________on this survey about what the residents at Mayview State Hospital may need to return to the community and to be successful there. I’m going to be asking you some questions about your family member’s life before she or he was admitted to the hospital and what you think she or he needs to live successfully in the community.  There are no right or wrong answers to these questions.     We appreciate your willingness to share your thoughts with us.  Your family member and the treatment team will also complete this survey.


 

This interview is the first step in a process that we all expect will lead to the discharge of your family member.  It’s important for you to understand that your family member won’t be discharged until a discharge plan is developed and all the necessary supports are in place. Please know that in working with your family member, we will put into place the services and supports he/she accepts as those needed to begin a successful life in the community.

The information you share in this interview will be used in two ways.  First, your responses will be used to help plan for your family member’s discharge.  Second, your responses will be combined anonymously with the responses from other interviews.  This will help us plan and develop the services and supports that will be most valuable to consumers leaving the hospital. 

INTERVIEWER:         Please record word for word responses in the family’s own words.


Living

 

Readiness for Discharge

 

1.      How ready do you think your family member is to live outside of the hospital?

Not ready  ___________           A little ready ___________  Ready ___________

 

 

2.      Why do you say that?

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

 

3.      What do you think your family member needs to do in order to further his or her mental health recovery?

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

 

4.          What do you think your family member needs to get to that place?

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________


 

 

5.    What do you think are your family member’s strengths?

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

6.      What are the three most important things you think your family member needs once he or she gets out of the hospital?

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

7.      What do you think your family member has learned from his or her hospital experience that will help him or her in the future?

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

8.      What are your hopes and dreams for your family member’s future?

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 


Housing/Living Environment

 

9.        I’m going to ask you several questions to find out the type of living place you recommend for your family member. I will read each housing description.  For each housing choice, I want you to tell me, in your opinion, whether you would recommend this living arrangement for your family member.

 

 

Housing Choices

 

Very much

 

A Little

 

Not At All

Live in a house, apartment, or room by himself or herself

 

 

 

Live in a house, apartment, room w/ family 

 

 

 

Live in a house, apartment, or room with roommate(s)

 

 

 

Live in a transitional rehabilitation group setting with other clients and 24/7 staff support on-site

 

 

 

Live in a permanent group setting w/other clients and 24/7 staff support on-site

 

 

 

Live in a nursing home because of severe medical problems

 

 

 


 

10.     In the living places you recommend above, how much professional support do you think your family member needs?

Ž           Daily support staff

ð           Weekly support staff

ð           Monthly support staff

ð           No support staff

ð           I don’t know

11.     What is the maximum number of people you recommend your family member lives with in the same bedroom?

 

Ž           No one

Ž           1

 

Ž           2

Ž           3

 

Ž           4

Ž           5

 

Ž           6

Ž           No preference

 

 

12.     What is the maximum number of people you recommend your family member lives with in the same house or apartment?

 

Ž           No one

Ž           1

 

Ž           2

Ž           3

 

Ž           4

Ž           5

 

Ž           6

Ž           7 or more

 



13.     Do you recommend that your family member live with a:

ð           Smoker

ð           Non-smoker

ð           No preference

 


 

14.         If your family member shares a living space, in your opinion, what age group do you recommend he/she live with? 

 

_______________________________________________________________________________________

 

 

15.         In your opinion, where did your family member live in the past several years that was most preferable to him or her?

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

16.         What County do you recommend your family member live in? 

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

 

17.         In your opinion, is there a particular neighborhood, town, or city you recommend your family member live in?

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 


 

18.     This is the last question under housing.  Here is a list of places your family member might go when he/she is living in the community.  I will read each place.  After I read each place, in your opinion, tell me if you recommend your family member be within walking distance or within a bus ride to this place.

 

 

Resources/Amenities

 

Able to Walk to…

 

Able to Take a Bus to…

a. See Family & Friends

 

 

b. A Bus Stop

 

 

c. Open spaces/Parks

 

 

d. Church, Synagogue, Mosque, or other place of worship

 

 

e. Malls/shopping areas

 

 

f. A Food bank

 

 

g. A Library

 

 

h. A Grocery Store

 

 

i. A Pharmacy

 

 

j. A Post Office

 

 

k. Museums

 

 

l. Sport/fitness centers

 

 

m. Drop-in Centers

 

 

n. Drug/Alcohol Counseling

 

 

o. Medical services

 

 

p. Dentist

 

 

q. Mental Health Clinic

 

 

r. Housing Supports

 

 

s. Self-help (AA, OA, NA…)

 

 

t. Other:

 

 

u. Other:

 

 

Learning

1.    How well do you think your family member can perform the following tasks?

 

Completely on his/her own

With some help

He or she doesn’t know how

Living Skills

 

 

 

Going places alone without help

 

 

 

Cooking/getting meals

 

 

 

Grocery shopping

 

 

 

Using appliances

 

 

 

Money Management

 

 

 

Budgeting his or her own money

 

 

 

Banking

 

 

 

Paying bills

 

 

 

Balancing a checkbook

 

 

 

Self-care and Safety

 

 

 

Maintaining personal appearance

 

 

 

Doing laundry

 

 

 

Keeping a clean living space

 

 

 

Recognizing dangerous situations

 

 

 

Contacting someone in an emergency

 

 

 

Finding a place to live

 

 

 

Finding a job

 

 

 

Mental Health Needs

 

 

 

Getting services

 

 

 

Making appointments

 

 

 

Keeping appointments

 

 

 

Following a medication schedule

 

 

 

Drug/alcohol treatment

 

 

 

Expressing/verbalizing what he/she needs

 

 

 

Finding someone to go to appointments with

 

 

 

Transportation

 

 

 

Having access to a car

 

 

 

Learning a bus schedule

 

 

 

Taking the bus

 

 

 

Getting a valid driver’s license

 

 

 

Other (specify)

 

 

 

2.    Does your family member know how to read?

                       

ð           Yes

 

ð           No

 

 

3.    If yes, does your family member have any trouble understanding what he/she is reading?

 

ð           Yes

 

ð           No

 

 

 

4.    Would you recommend that your family member learn how to use a computer?

 

ð           Yes

 

ð           No

 

 

5.    Do you recommend that your family member pursue any education?

 

ð           Yes

 

ð           No

 

 

6.    If yes, what kind?

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

7.    Do you recommend that your family member become active in the consumer movement?

 

ð           Yes

 

ð           No

 

 


Socializing

 

  1. In your opinion, who do you think has meant the most to your family member in the last six months?

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

  1. How do you recommend your family member stay in contact with them?

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

  1. Do you recommend that your family member receive help with any of the following?

 

 

Yes

No

Finding things to do

 

 

Getting a driver’s license

 

 

Reading

 

 

Writing

 

 

Safe sexual practices

 

 

Learning about his/her neighborhood

 

 

Dealing with authority figures

 

 

Family relationships

 

 

Meeting people/making friends

 

 

Paying attention to time

 

 

Structuring free time

 

 

Communicating with others regularly in social situations

 

 

Other (specify)

 

 

 

 

  1. Do you recommend your family member use spiritual supports or connections in his or her recovery process?

 

ð           Yes

 

ð           No

 

 

  1. If yes, please describe your recommendations.

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

  1. Do you recommend that your family member talk to someone who has been in the hospital and is now living in the community?

 

ð           Yes

 

ð           No

 

 

 

Working

 

1.    Are you aware that your family member can work in the community and still receive benefits?

ð           Yes

 

ð           No

 

 

 

2.    Would you recommend that your family member work:

 

ð           Full-Time

 

ð           Volunteer

 

ð           Part-Time

ð           Not at all

 

 

 

3.    What type of work do you recommend your family member pursue?

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

4.    Do you recommend that your family member receive job training?

 

ð           Yes

 

ð           No

 

 

 

Clinical/Medical

 

1.      Does your family member have any of the following disabilities?

 

ð           Visual impairment

 

ð           Hearing impairment

 

ð           Mobility impairment

 

ð           No physical limitations

 

            Other:

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 


2.      Does your family member have:

 

ð           Yes

 

ð           No

 

 

A primary care physician/family doctor?

 

 

ð           Yes

 

ð           No

 

 

A dentist?

 

 

 

3.      Which of the following tools or treatments do you recommend your family member receive for their mental wellness?

 

ð     Individual therapy (just your family member and the therapist)

ð     Talk therapy

ð     Group therapy with other patients and therapist

ð     Individual visits with a psychiatrist

ð     Group visits with a psychiatrist

ð     Psychiatrist/therapist who visits your family member where he/she lives

ð     Family therapy to help your family member get along better with your family

 

ð     Partial hospitalization

ð     Clubhouse

ð     Drop-in center

ð     Meditation

ð     Art therapy

ð     Music therapy

ð     Pet therapy

ð     Pet ownership

 

ð     Dance therapy

ð     Relaxation techniques

ð     Spirituality (in a group setting)

ð     Spirituality (alone)

ð     Proper nutrition

ð     Massage therapy

ð     Acupuncture

ð     Exercise

 

 

Other therapies/assistance:

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 


 

4.      In your opinion, does your family member have any unsafe behaviors?

 

ð           Yes

 

ð           No

 

 

5.      If yes, what?

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

6.      How often can you tell when your family member is starting to have mental or emotional problems?

ð           Never

 

ð           Sometimes

 

ð           Always

ð           Rarely

ð           Often

 

 

 

7.      When you notice that your family member is starting to have mental or emotional problems, how often can he or she take care of those problems before they become worse?

 

ð           Never

 

ð           Sometimes

 

ð           Always

ð           Rarely

ð           Often

 

 


8.      In your opinion, does your family member have relapse prevention tools to use when he or she returns to the community?

ð           Yes

 

ð           No

 

 

9.      To your knowledge, has your family member developed an advance directive?

 

ð           Yes

 

ð           No

 

 

10. To your knowledge, does your family member need information on who to call or where to go if she or he needs an advocate to help with insurance issues, treatment concerns, housing concerns, or civil rights?

 

In the hospital:

ð           Yes

 

ð           No

 

 

In the community:

ð           Yes

 

ð           No

 

 

 


 

Family Supports

1.      Do you, as a family member, need assistance in any of the following areas in order to help make this discharge successful?

 

 

Yes

No

Linkage with other families

 

 

Hotlines

 

 

Outpatient mental health care (case management, counseling, management of mental illness, etc.)

 

 

Outpatient drug and alcohol care (counseling, case management, management of relapse, etc.)

 

 

Learning about dosage, side effects, purpose of medications

 

 

Assistance in understanding the medical care your family member needs

 

 

Family psycho-education

 

 

Understanding SS, SSI, Insurance/other benefits

 

 

Other:

 

 

Other:

 

 

 

2.      In your opinion, is there anything else you think your family member needs to help make his/her discharge a comfortable and successful community living experience? 

 

For example: in-home fixtures for physical accessibility; a first floor room or an elevator, special ambulation devices like hearing and visual supports; special dietary programs; freedom from specific allergens, objects, people, buildings, or anything associated with any fears he/she has such as (animals, power plants, police stations, etc.), and finally, any special linguistic, cultural, ethnic, sexual needs.

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

3.      Is there anything else you need to help make this discharge a comfortable and successful community living experience?

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

 

4.      How satisfied are you with the family assessment you just completed?

ð           Very satisfied

 

ð           Neutral

 

ð           Very Unsatisfied

ð           Satisfied

ð           Unsatisfied

 

 

5.      Please explain:

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

 

 

 

Thanks for sharing your comments and time.