(1a) Background Information for Case Evaluation



Please answer the following confidential questions and return it as soon as possible.

Ask other family members and friends for their input: they will often provide an additional perspective. If friends feel uncomfortable giving this information, feel free to have them contact me directly.


It is very important to have all relevant personal information that may have a bearing on the case. It is assumed that the group member will have divulged this information to the group. The more information you can give, the more easily an Intervention/Mediation can be planned.


Please include a recent photo of the group member.





Date:
  
Your name:

Address:
City:
State:
Zip:
Country:

Phone numbers:
Fax number:
E-mail:







Who referred you?

What is your relationship to the group member?
  
What is the name of the group?

Group members name?
    
Age?



_________________________________________________________________
FAMILY BACKGROUND

   Father's name and occupation:
   Mother's name and occupation:
   Parents: Married [ ] Separated [ ] Divorced [ ]
   Spouse/Siblings:
   Age:
   Sex:
   Name:
   Occupation:
   Married:
   Education:
   Telephone:
   Fax:
   Email:


PERSONAL BACKGROUND


1. Is he/she Married [ ] Separated [ ] Divorced [ ] In a committed relationship [ ]
If so, provide name, age, education, occupation, and other relevant information about spouse or partner. Include whether that person is also affiliated with the group.

2. Is she/he a parent? If so, provide name, age, education, and other relevant information about the child(ren). 


3. Where does he/she currently live? Alone or with others?


4. Who has been the closest to him/her? Briefly describe their relationship, including the following points:
a) Has the relationship remained the same since group involvement?

b) If not, specify how the relationship has changed?

5. How often do you see him/her since involvement? Under what circumstances and for what length of time? What do you talk about? Has this changed from how he/she previously related to you?

6. Generally describe the family (or person’s) environment or lifestyle before involvement with the group.
a) Significant relationships, such as best friends, boy/girlfriends, and any especially close relatives, or lack of such intimate friendships:

b) Communication patterns between family members, both good and bad:

c) Fights and estrangements in the family that may have had an impact on him/her and/or other family members:

d) Significant emotional or other personality changes noticed by the family or friends:

e) Any history of alcohol or drug abuse in the family (Note: this space for family only, later this same question is asked about the individual):

f) Any history of physical or sexual abuse in the family, and if

so, who was involved:
g) Describe any family dysfunction’s or long-term or recent difficulties, if any:

7. Who within immediate family or friendship network is or is not willing to help with the Intervention/Mediation? If someone is unwilling to help, why?

8. Describe how family members have emotionally reacted to the person's group involvement. Include the types of reactions and by whom.

9. Does he/she react positively to specific family members or friends?
Is there someone he/she talks with more freely?



EDUCATIONAL BACKGROUND

10. What level of education has been completed?


a) Major or field of specialty:

b) List degrees or credentials received:

c) Grade point average:

d) Any problems at school or academically:

e) Special interests:

f) Special talents:

g) Other:

________________________________________________________________________


PHYSICAL AND MENTAL HEALTH

11. Describe her/his general health condition, to the best of your knowledge.

12. Describe physical and health condition prior to joining group.

13. Has she/he ever experienced any trauma, such as:

a) Accident

b) Hospitalization

c) Extreme illness

d) Psychiatric problems

e) Victim of a rape or an assault

f) Death of a loved one

g) Death of a pet

h) Concussion or coma

If yes to any of the above, please describe in as much detail as possible the following:
a) When it occurred
b) How long it lasted
c) What recovery was like and how long it took
d) Any medications taken
e) Any temporary or lasting personality changes after the trauma
f) Diagnosis given by a doctor involved at the time, if any
g) How she/he subsequently dealt with the experience
h) Any change in his/her method of dealing with traumatic or upsetting situations since group involvement, and if so, describe

14. Has there been any prior drug or alcohol use? If so, when, what was used, and to what degree? To your knowledge, is there still a problem? If not, how has this been dealt with?

15. Describe his/her social, emotional, and psychological well-being prior to involvement.

16. Include any history of previous problems, including but not limited to the following:

a) Death of a relative or close friend

b) Breakup of a meaningful relationship

c) Difficulty with intimate relationships

d) Other

17. Any history of mental illness? If so, please describe in as much detail, including diagnosis, when it occurred, duration, treatment, and so forth. Please indicate if he/she is currently on any medications, the diagnosis, and who prescribes the drugs.

18. Any history of psychotherapy or other type of counseling?

19. Any history of involvement with criminal activity? Detention? Halfway house? Prison?



SOCIAL SKILLS

20. Describe his/her communication skills and abilities prior to group involvement. Was she/he

a) Generally ready to join in conversations?

1) with family

2) with peers

3) with strangers
b) Naturally withdrawn?
c) Rarely responsive, no matters what the situation?
d) Only able to communicate on certain subjects, and if so, which?
21. Describe how any of the above has or has not changed since joining the group. Be specific.

22. How did she/he relate on an emotional level prior to group involvement?
a) Generally show or express feelings or emotions freely?
b) Usually try to hide feelings and emotions?
c) Whether a or b, describe how feelings and emotions were handled.
d) If this has changed, specify exactly how:


23. What were his/her typical physical reactions, or body language, when:
a) Nervous
b) Anxious
c) Angry
d) Resentful
e) Fearful
f) Defensive or hostile
g) Ready to leave in anger


24. Describe if and how any of the above responses have changed since involvement with the group. Be as specific as possible.

25. In the past, how did she/he respond during times of stress? For example, run away, hide, deny what was going on, make fun, get angry, get defensive, try to resolve issues through talking, try other methods of resolving matters?

26. Describe if and how his/her response to stress has changed since involvement with the group.

27. Who has the most influence or clout with her/him in the following ways:
a) Emotionally and how does this transpire?
b) Intellectually or logically, and how does this transpire?
c) Other:


PRIOR BACKGROUND

28. What were his/her primary interests?

29. Was she/he involved with social or political activities?

30. What were his/her hobbies or favorite pleasurable interests?

31. Has she/he ever been involved with other "alternative" groups or ideas? If so, describe.

32. Please list all prior group and/or religious involvement, other than that of the family.

33. What is the family's religious or spiritual background, including degree of involvement in related activities over the years? Also describe his/her degree of interest and involvement in the family's religion prior to joining the group.

34. What is or was her/his primary interest in literature? Provide authors and titles.

35. Has he/she ever practiced meditation or other such practices (e.g., yoga, bodywork, chanting)?

If so dates, length of time.

36. Any prior involvement with metaphysics?

37. Any prior involvement with holistic healing or alternative medicines?

38. Any prior involvement or attraction to "extreme" ideologies or groups?


EMPLOYMENT HISTORY

39. How does the person support himself/herself financially? Include current occupation.

40. List previous occupations (what, where, for how long, reasons for leaving).

41. Describe previous career goals.
42. Does the family provide any financial support at this time? If so, when and how much?


HISTORY OF GROUP INVOLVEMENT

43. Date recruited?

44. Where recruited?

45. Describe to the best of your knowledge, how the recruitment transpired, the events that led up to it, where and how initial contact was made, and who was involved. What was the length of time from initial contact to present level of commitment?
46. Please supply whatever of the following you have knowledge of:

a) Names of group members and their areas of responsibility:

b) Names and description of top leader (or leaders):

c) Describe your family member's level of commitment to the group (e.g., full-time, taking courses, with group several times a week):

d) Describe what he/she does in the group, including group studies, practices, and any areas of responsibility that you are aware of:

e) Where he/she is located, including whether living with the group or other members:

f) Describe to the best of your understanding what the group says it stands for:

47. What reason did she/he give for joining the group?

48. What kind of communication he/she has had with family and friends since joining the group?

49. How much time does he/she spend with the family now, and with which family members?
50. How does he/she talk about the group? Its practices? The leader? Activities? Does he/she speak readily about the group? Or rarely? What is generally said? To whom? Who initiates the conversation?

51. What group level or title has he/she attained?

52. Has she/he ever expressed any doubts or difficulties with the group? If so, what were they? Be as specific as you can. Include to whom and under what circumstances.

53. Has his/her personality and/or behavior changed since joining the group? If so, in what way? Be as specific as you can.

54. Do her/his emotions/feelings get activated when group or someone brings up his/her involvement with it?

a) If so, what specific statements trigger her/him the most?
b) How does he/she respond at those times?
c) How does he/she respond to criticism?

55. Describe what contact you have had with the group or any of its members. What are your impressions? How do members act around you or respond to you? 

_________________________________________________________________________________
Intervention/Mediation PREPARATION

56. List books you have read related to this issue.

57. List other professionals to whom you have spoken.

58. Describe any actions you have taken or conversations you have had with him/her up to now. Include how she/he has reacted.

59. Is there any limitation of resources that I should know about?

60. Is there anything else pertinent that I should know about?

61. Are your goals to give her/him a more informed basis for choice regarding his/her involvement or affiliation with the specific group?

62. What other expectations do you have for the Intervention/Mediation?



By returning this Background For Case Evaluation Form:


  1. I acknowledge that I have received, read, understand and accept Patrick Ryan's "FEE SCHEDULE (1c)," dated 12/16, and effective until 12/31/17.
  2. I acknowledge that I have received, read, understand and accept  Joseph Kelly's "FEE SCHEDULE(1d)," dated 12/16, and effective until 12/31/17.



Send via (Mail, Fax, e-mail):

Joseph Kelly/ Patrick Ryan
1300 S. 13th Street
Philadelphia, PA 19147
Phone: 215.467.4939; 
e-mail: pryan19147@gmail.com;
web: http://www.cultmediation.com
http://www.intervention101.com/



©1997-2011 Joseph Kelly & Patrick Ryan
Rev: 01/01, 07/03, 8/04, 9/05,  4/06, 9/06, 12/08, 09/11, 11/12, 12/16 “Background Information For Case Evaluation”