I.Interview with parents (while children are observed in a playroom situation)

A.Describe your children (use blackboard - ordinal position)
schoolwork, hobbies, athletic, etc.

B.How does each child find his or her place in the family?

C.What problems revolve around:
        getting uphomework
        meal timechores
        T.V.bedtime

D.Is there something in your family that needs to be better?

E.Would you like to make a change?

F. I would like to have family admit that they are bankrupt and nothing has worked in improving the family.

II. Interview with children (parents leave the conference room)

A. Do you know why you are here today?
B. How can we make things better at home?
C. Who is the smart one?
D. Who is the good child?
E. Who is father's favorite?
F. Who is mother's favorite?
G. Who is best in sports?
H. What do each of you do best?
I. Is there anything that bothers you in the family that you would like to change?

III. Interview with entire family.

Summary and plans for the coming week.
 

RECOMMENDATIONS:

1. Individual parent time for each child, each day
2. Family conference /one/ per week
3. One family activity per week
4. Each family member does chores

Name:
Date:

1. The reason for coming:
 
 

2. The history of this concern:
 
 

 3. Current Life Tasks  (How things are going in these areas; what they want)  Rate 1 - 5

Occupation

Friendship

Opposite Sex

Self

Meaning

Leisure

Parenting

Father's age __ Occupation     Mother's age __  Occupation
Personality, type of person:    Personality, type of person:

Ambitions for children:     Ambitions for children:

Relationship to children:     Relationship to children:

Way you are similar/different     Way you are similar/different
 from father?       from mother?

5. Nature of parents' relationship:

6. Any other parental figures?

7. Description of siblings.
(1)  Who is the most different from you?    How?
(2)  Who is most like you?    How?
(3)  What kind of child were you?
(4)  Were there any unusual talents, achievements, or ambitions?
(5)  Any sickness, accidents?
(6)  Childhood fears?

8. Physical and Sexual Development:
 

9. Social Development:
 

10. School and Work Experiences:
 

11. Ratings: List highest and lowest sibling for each attribute.  If client is at neither extreme, indicate position in relationship to siblings.
 
 

(1)  Intelligence
(13)  Critical of self

(2)  Grades & general standards of
        achievement
(14)  Charming; Trying to please

(3)  Hardest worker; Industrious
(15)  Sociable; Friendships Withdrawn

(4)  Responsible
(16)  Sense of humor

(5)  Methodical, Neat
(17)  Demanded and got own way

(6)  Athletic
(18)  Temper and Stubborn

(7)  Appearance
(19)  Sensitive; Easily Hurt

(8)  Mischievous
(20)  Idealistic

(9)  Rebellious:  openly, covertly
(21)  Materialistic

(10)  Conforming
(22)  Excitement Seeker

(11)  Standards of right/wrong, Morals
(23)  Most spoiled

(12)  Critical of others
(24)  Most punished

12. Early Recollections - How far back can you remember?  (Obtain recollections of specific incidents, with as many details as possible, including the client's reaction at the time)