At-Risk Family Assessment Template
Family Identification
Family Name
Assessor Name
Date of Assessment
Family Members
Demographics
Address
Phone Number
Primary Language
Household Income
Referral Source
How was the family referred?
Primary Concerns
List main risk factors/concerns
Current Supports/Resources
Identify support systems
Assessment Observations
Observations during assessment
Needs/Interventions
Recommended interventions
Follow-Up Plan
Next steps