Special Needs Family Assessment
1. Family Information
Name of Family
Date
Address
Contact Person
Relationship to Child
Phone Number
2. Family Members
Name
Age
Relationship
Occupation/School
Health Concerns
3. Child with Special Needs
Child's Name
Date of Birth
Diagnosis
Current Health Status
Current Services/Interventions
4. Family Strengths and Needs
What are the family's strengths?
What challenges is the family facing?
Current supports (community, school, extended family, etc.)
Additional supports needed
5. Goals
Family's short-term goals
Family's long-term goals
6. Additional Notes