Family Dynamics Questionnaire

FAMILY DYNAMICS QUESTIONNAIRE

Parties and Identifying Information

Date Completed:

WHEREAS (Recitals)

WHEREAS, Client Name: seeks a structured assessment of family relationships, functioning, and needs to inform planning for family-focused support and/or therapeutic services; and

WHEREAS, Practitioner Name: will receive and use the information provided in this questionnaire to develop an informed plan of work for the family, subject to the confidentiality and consent provisions set forth below.

Family and Household Information

Number of people living in household:

List household members (name, age, relationship). Use additional pages if necessary.

Age:    Relationship:

Age:    Relationship:

Age:    Relationship:

Family Functioning and Patterns

How would you describe communication patterns in the family?

Open and direct conversations    Avoidant / Indirect    Frequent conflict    Silent treatment / withdrawal

Health, Safety, and Legal Considerations

Yes    No

Is there any history or current concern of domestic violence, abuse, or child safety risk?

Yes    No

Goals, Scope of Work and Use of Information

Payment Terms (if applicable)

Standard fee for family assessment and consultation: $

Late payment fee (percent per month): %

Term and Termination (if services are engaged)

Start Date:    Anticipated End Date:

Termination requires written notice delivered to the other party. Notice period (days):

Either party may terminate for material breach, failure to pay fees, or safety concerns. Fees incurred for services rendered prior to termination remain payable.

Confidentiality and Limits

All information supplied in this questionnaire will be treated as confidential and used solely for the purposes described in the Scope of Work. The practitioner will not disclose identifiable information except where required by law or professional duty, including but not limited to:

• Imminent risk of serious harm to a person;
• Allegations or evidence of abuse or neglect of a child or vulnerable adult;
• When disclosure is ordered by a court of competent jurisdiction.

By providing information herein, Client acknowledges understanding of these limits to confidentiality and consents to the practitioner’s use of the information to inform assessment, planning, and referrals as needed.

Governing Law; Entire Agreement; Certification

Governing Law: This Questionnaire and any related engagement of services shall be governed by the substantive law of the state selected by the practitioner and client by mutual agreement. Any dispute arising out of the interpretation of the use of this information shall be resolved in the appropriate state or federal court of competent jurisdiction.

Entire Agreement: The terms and representations contained in this Questionnaire, Scope of Work, and any signed engagement letter constitute the entire understanding between the parties with respect to the assessment and use of the information provided herein, superseding prior oral or written communications on the same subject.

Certification: I certify that the information provided in this questionnaire is true and accurate to the best of my knowledge. I understand that knowingly providing materially false information may affect the practitioner’s ability to provide appropriate services.

Acknowledgment and Consent

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