Domain: Living

Family Assessment Tool

Name of interviewer: _______________________________________

Date of assessment: ___ ___ / ___ ___ / ___ ___ ___ ___

Patient’s First Name: _________________________ MI: ______ Last Name:______________________________

County: _______________________________________

Family Member’s First Name: _________________________ Last Name:______________________________

Address: ________________________________________________Phone Number: ________________

Relationship to Patient: __________

Does Patient Speak English? _______ If not, what is Primary Language? _________________________

Please read to the family member:

My name is ______________________________________, and I am also a family member of a mental health consumer. I am working with the _____________________________on this survey about what the residents at Mayview State Hospital may need to return to the community and to be successful there. I’m going to be asking you some questions about your family member’s life before she or he was admitted to the hospital and what you think she or he needs to live successfully in the community. There are no right or wrong answers to these questions. We appreciate your willingness to share your thoughts with us. Your family member and the treatment team will also complete this survey.

This interview is the first step in a process that we all expect will lead to the discharge of your family member. It’s important for you to understand that your family member won’t be discharged until a discharge plan is developed and all the necessary supports are in place. Please know that in working with your family member, we will put into place the services and supports he/she accepts as those needed to begin a successful life in the community.

The information you share in this interview will be used in two ways. First, your responses will be used to help plan for your family member’s discharge. Second, your responses will be combined anonymously with the responses from other interviews. This will help us plan and develop the services and supports that will be most valuable to consumers leaving the hospital.

INTERVIEWER: Please record word for word responses in the family’s own words.

Living

Readiness for Discharge

1. How ready do you think your family member is to live outside of the hospital?

Not ready ___________ A little ready ___________ Ready ___________

2. Why do you say that?

_________________________________________________________________________________________________

3. What do you think your family member needs to do in order to further his or her mental health recovery?

_________________________________________________________________________________________________

4. What do you think your family member needs to get to that place?

_________________________________________________________________________________________________

5. What do you think are your family member’s strengths?

_________________________________________________________________________________________________

6. What are the three most important things you think your family member needs once he or she gets out of the hospital?

_________________________________________________________________________________________________

7. What do you think your family member has learned from his or her hospital experience that will help him or her in the future?

_________________________________________________________________________________________________

8. What are your hopes and dreams for your family member’s future?

_________________________________________________________________________________________________

Housing/Living Environment

9. I’m going to ask you several questions to find out the type of living place you recommend for your family member. I will read each housing description. For each housing choice, I want you to tell me, in your opinion, whether you would recommend this living arrangement for your family member.

Housing Choices	Very much	A Little	Not At All
Live in a house, apartment, or room by himself or herself
Live in a house, apartment, room w/ family
Live in a house, apartment, or room with roommate(s)
Live in a transitional rehabilitation group setting with other clients and 24/7 staff support on-site
Live in a permanent group setting w/other clients and 24/7 staff support on-site
Live in a nursing home because of severe medical problems

10. In the living places you recommend above, how much professional support do you think your family member needs?

Ž Daily support staff

ð Weekly support staff

ð Monthly support staff

ð No support staff

ð I don’t know

11. What is the maximum number of people you recommend your family member lives with in the same bedroom?

Ž No one

Ž 1

Ž 2

Ž 3

Ž 4

Ž 5

Ž 6

Ž No preference

12. What is the maximum number of people you recommend your family member lives with in the same house or apartment?

Ž No one

Ž 1

Ž 2

Ž 3

Ž 4

Ž 5

Ž 6

Ž 7 or more

13. Do you recommend that your family member live with a:

ð Smoker

ð Non-smoker

ð No preference

14. If your family member shares a living space, in your opinion, what age group do you recommend he/she live with?

_______________________________________________________________________________________

15. In your opinion, where did your family member live in the past several years that was most preferable to him or her?

_________________________________________________________________________________________

16. What County do you recommend your family member live in?

__________________________________________________________________________________________

17. In your opinion, is there a particular neighborhood, town, or city you recommend your family member live in?

___________________________________________________________________________________________

18. This is the last question under housing. Here is a list of places your family member might go when he/she is living in the community. I will read each place. After I read each place, in your opinion, tell me if you recommend your family member be within walking distance or within a bus ride to this place.

Resources/Amenities	Able to Walk to…	Able to Take a Bus to…
a. See Family & Friends
b. A Bus Stop
c. Open spaces/Parks
d. Church, Synagogue, Mosque, or other place of worship
e. Malls/shopping areas
f. A Food bank
g. A Library
h. A Grocery Store
i. A Pharmacy
j. A Post Office
k. Museums
l. Sport/fitness centers
m. Drop-in Centers
n. Drug/Alcohol Counseling
o. Medical services
p. Dentist
q. Mental Health Clinic
r. Housing Supports
s. Self-help (AA, OA, NA…)
t. Other:
u. Other:

Learning

1. How well do you think your family member can perform the following tasks?

	Completely on his/her own	With some help	He or she doesn’t know how
Living Skills
Going places alone without help
Cooking/getting meals
Grocery shopping
Using appliances
Money Management
Budgeting his or her own money
Banking
Paying bills
Balancing a checkbook
Self-care and Safety
Maintaining personal appearance
Doing laundry
Keeping a clean living space
Recognizing dangerous situations
Contacting someone in an emergency
Finding a place to live
Finding a job
Mental Health Needs
Getting services
Making appointments
Keeping appointments
Following a medication schedule
Drug/alcohol treatment
Expressing/verbalizing what he/she needs
Finding someone to go to appointments with
Transportation
Having access to a car
Learning a bus schedule
Taking the bus
Getting a valid driver’s license
Other (specify)

2. Does your family member know how to read?

ð Yes

ð No

3. If yes, does your family member have any trouble understanding what he/she is reading?

ð Yes

ð No

4. Would you recommend that your family member learn how to use a computer?

ð Yes

ð No

5. Do you recommend that your family member pursue any education?

ð Yes

ð No

6. If yes, what kind?

_________________________________________________________________________________________

7. Do you recommend that your family member become active in the consumer movement?

ð Yes

ð No

Socializing

In your opinion, who do you think has meant the most to your family member in the last six months?

_________________________________________________________________________________________

How do you recommend your family member stay in contact with them?

_________________________________________________________________________________________

Do you recommend that your family member receive help with any of the following?

	Yes	No
Finding things to do
Getting a driver’s license
Reading
Writing
Safe sexual practices
Learning about his/her neighborhood
Dealing with authority figures
Family relationships
Meeting people/making friends
Paying attention to time
Structuring free time
Communicating with others regularly in social situations
Other (specify)

Do you recommend your family member use spiritual supports or connections in his or her recovery process?

ð Yes

ð No

If yes, please describe your recommendations.

_________________________________________________________________________________________

Do you recommend that your family member talk to someone who has been in the hospital and is now living in the community?

ð Yes

ð No

Working

1. Are you aware that your family member can work in the community and still receive benefits?

ð Yes

ð No

2. Would you recommend that your family member work:

ð Full-Time

ð Volunteer

ð Part-Time

ð Not at all

3. What type of work do you recommend your family member pursue?

_________________________________________________________________________________________

4. Do you recommend that your family member receive job training?

ð Yes

ð No

Clinical/Medical

1. Does your family member have any of the following disabilities?

ð Visual impairment

ð Hearing impairment

ð Mobility impairment

ð No physical limitations

Other:

_________________________________________________________________________________________

2. Does your family member have:

ð Yes

ð No

A primary care physician/family doctor?

ð Yes

ð No

A dentist?

3. Which of the following tools or treatments do you recommend your family member receive for their mental wellness?

ð Individual therapy (just your family member and the therapist)

ð Talk therapy

ð Group therapy with other patients and therapist

ð Individual visits with a psychiatrist

ð Group visits with a psychiatrist

ð Psychiatrist/therapist who visits your family member where he/she lives

ð Family therapy to help your family member get along better with your family

ð Partial hospitalization

ð Clubhouse

ð Drop-in center

ð Meditation

ð Art therapy

ð Music therapy

ð Pet therapy

ð Pet ownership

ð Dance therapy

ð Relaxation techniques

ð Spirituality (in a group setting)

ð Spirituality (alone)

ð Proper nutrition

ð Massage therapy

ð Acupuncture

ð Exercise

Other therapies/assistance:

_________________________________________________________________________________________

4. In your opinion, does your family member have any unsafe behaviors?

ð Yes

ð No

5. If yes, what?

_________________________________________________________________________________________

6. How often can you tell when your family member is starting to have mental or emotional problems?

ð Never

ð Sometimes

ð Always

ð Rarely

ð Often

7. When you notice that your family member is starting to have mental or emotional problems, how often can he or she take care of those problems before they become worse?

ð Never

ð Sometimes

ð Always

ð Rarely

ð Often

8. In your opinion, does your family member have relapse prevention tools to use when he or she returns to the community?

ð Yes

ð No

9. To your knowledge, has your family member developed an advance directive?

ð Yes

ð No

10. To your knowledge, does your family member need information on who to call or where to go if she or he needs an advocate to help with insurance issues, treatment concerns, housing concerns, or civil rights?

In the hospital:

ð Yes

ð No

In the community:

ð Yes

ð No

Family Supports

1. Do you, as a family member, need assistance in any of the following areas in order to help make this discharge successful?

	Yes	No
Linkage with other families
Hotlines
Outpatient mental health care (case management, counseling, management of mental illness, etc.)
Outpatient drug and alcohol care (counseling, case management, management of relapse, etc.)
Learning about dosage, side effects, purpose of medications
Assistance in understanding the medical care your family member needs
Family psycho-education
Understanding SS, SSI, Insurance/other benefits
Other:
Other:

2. In your opinion, is there anything else you think your family member needs to help make his/her discharge a comfortable and successful community living experience?

For example: in-home fixtures for physical accessibility; a first floor room or an elevator, special ambulation devices like hearing and visual supports; special dietary programs; freedom from specific allergens, objects, people, buildings, or anything associated with any fears he/she has such as (animals, power plants, police stations, etc.), and finally, any special linguistic, cultural, ethnic, sexual needs.

_______________________________________________________________________________________

3. Is there anything else you need to help make this discharge a comfortable and successful community living experience?

_______________________________________________________________________________________

4. How satisfied are you with the family assessment you just completed?

ð Very satisfied

ð Neutral

ð Very Unsatisfied

ð Satisfied

ð Unsatisfied

5. Please explain:

_________________________________________________________________________________________

Thanks for sharing your comments and time.

Live in a house, apartment, room w/ family

Able to Walk to…

Able to Take a Bus to…