Family Dynamics Screening Checklist
Client Name
Date
Assessor
Household Members (List relationship and age)
Screening Items (Check all that apply):
Frequent family conflict
Poor communication
Lack of parental support or supervision
Unclear family roles
Substance abuse in family
Mental health concerns in family
Exposure to domestic violence
Financial difficulties
Recent major family changes or transitions
Other concerns
Identified Family Strengths
Assessor Observations / Additional Concerns