Family Members
List family members, relationship
to client, age, and remarks.
Indicate if there is a family
history of mental illness.
Indicate your assessment of any
family conflicts, including current household conflicts but not
in any intimate relationships (spouse, etc.)
Indicate if, in your opinion,
family conflicts may contribute to mental health issues.
Comments
Relationships
Describe the client’s relationship status, by selecting from the
list or typing in another description.
Partner/Spouse Name, if applicable
Describe the client’s sexual
orientation by selecting from the list or typing in another
description.
List any past significant
relationships.
Indicate your assessment of the
severity of relationship conflicts.
Indicate if relationship conflicts
may contribute to mental health issues
Comments
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