Kelly/ Patrick Ryan
Philadelphia, PA 19147
215.467.4939; Fax: 267.386.2329; e-mail: firstname.lastname@example.org
Background Information For Case Evaluation
answer the following confidential questions and return it as soon as
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.
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 can be planned.
is your relationship to the group member?
Please include a recent photo of the group member.
is the name of the group?
Father's name and occupation:
Mother's name and occupation:
Parents: Married [ ] Separated [ ] Divorced [ ]
he/she Married [ ] Separated [ ] Divorced [ ] In a committed relationship 
provide name, age, education, occupation, and other relevant information
about spouse or partner. Include whether that person is also affiliated with
she/he a parent? If so, provide name, age, education, and other relevant
information about the child(ren).
does he/she currently live? Alone or with others?
has been the closest to him/her? Briefly describe their relationship,
including the following points:
the relationship remained the same since group involvement?
not, specify how the relationship has changed?
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?
Generally describe the family (or personís) environment or lifestyle before
involvement with the group.
Significant relationships, such as best friends, boy/girlfriends, and any
especially close relatives, or lack of such intimate friendships:
Communication patterns between family members, both good and bad:
and estrangements in the family that may have had an impact on him/her
and/or other family members:
Significant emotional or other personality changes noticed by the family or
history of alcohol or drug abuse in the family (Note: this space for family
only, later this same question is asked about the individual):
history of physical or sexual abuse in the family, and if
Describe any family dysfunctionís or long-term or recent difficulties, if
within immediate family or friendship network is or is not
to help with the intervention? If someone is unwilling to
Describe how family members have emotionally reacted to the personís group
involvement. Include the types of reactions and by whom.
he/she react positively to specific family members or friends?
someone he/she talks with more freely?
level of education has been completed?
or field of specialty:
degrees or credentials received:
problems at school or academically:
PHYSICAL AND MENTAL HEALTH
Describe her/his general health condition, to the best of your knowledge.
Describe physical and health condition prior to joining group.
she/he ever experienced any trauma, such as:
of a rape or an assault
of a loved one
of a pet
Concussion or coma
If yes to
any of the above, please describe in as much detail as possible the
long it lasted
recovery was like and how long it took
temporary or lasting personality changes after the trauma
Diagnosis given by a doctor involved at the time, if any
she/he subsequently dealt with the experience
change in his/her method of dealing with traumatic or upsetting situations
since group involvement, and if so, describe
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?
Describe his/her social, emotional, and psychological well-being prior to
Include any history of previous problems, including but not limited to the
of a relative or close friend
Breakup of a meaningful relationship
Difficulty with intimate relationships
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.
history of psychotherapy or other type of counseling?
history of involvement with criminal activity? Detention?
Describe his/her communication skills and abilities prior to group
involvement. Was she/he
Generally ready to join in conversations?
responsive, no matters what the situation?
able to communicate on certain subjects, and if so, which?
Describe how any of the above has or has not changed since joining the
group. Be specific.
did she/he relate on an emotional level prior to group involvement?
Generally show or express feelings or emotions freely?
Usually try to hide feelings and emotions?
Whether a or b, describe how feelings and emotions were handled.
this has changed, specify exactly how:
were his/her typical physical reactions, or body language, when:
Defensive or hostile
to leave in anger
Describe if and how any of the above responses have changed since
involvement with the group. Be as specific as possible.
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?
Describe if and how his/her response to stress has changed since involvement
with the group.
has the most influence or clout with her/him in the following ways:
Emotionally and how does this transpire?
Intellectually or logically, and how does this transpire?
were his/her primary interests?
she/he involved with social or political activities?
were his/her hobbies or favorite pleasurable interests?
she/he ever been involved with other "alternative" groups or ideas? If so,
Please list all prior group and/or religious involvement, other than that of
is the familyís 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 familyís religion prior to joining
is or was her/his primary interest in literature? Provide authors and
he/she ever practiced meditation or other such practices (e.g., yoga,
dates, length of time.
prior involvement with metaphysics?
prior involvement with holistic healing or alternative medicines?
prior involvement or attraction to "extreme" ideologies or groups?
does the person support himself/herself financially? Include current
previous occupations (what, where, for how long, reasons for leaving).
Describe previous career goals.
the family provide any financial support at this time? If so, when and how
HISTORY OF GROUP INVOLVEMENT
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?
Please supply whatever of the following you have knowledge of:
of group members and their areas of responsibility:
and description of top leader (or leaders):
Describe your family memberís level of commitment to the group (e.g.,
full-time, taking courses, with group several times a week):
Describe what he/she does in the group, including group studies, practices,
and any areas of responsibility that you are aware of:
he/she is located, including whether living with the group or other members:
Describe to the best of your understanding what the group says it stands
reason did she/he give for joining the group?
kind of communication he/she has had with family and friends since joining
much time does he/she spend with the family now, and with which family
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?
group level or title has he/she attained?
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
his/her personality and/or behavior changed since joining the group? If so,
in what way? Be as specific as you can.
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?
does he/she respond at those times?
does he/she respond to criticism?
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?
books you have read related to this issue.
other professionals to whom you have spoken.
Describe any actions you have taken or conversations you have had with
him/her up to now. Include how she/he has reacted.
there any limitation of resources that I should know about?
there anything else pertinent that I should know about?
your goals to give her/him a more informed basis for choice regarding
his/her involvement or affiliation with the specific group?
other expectations do you have for the intervention?
returning this Background For Case Evaluation Form:
1) I acknowledge that I have
received, read, understand and accept Patrick Ryan's "FEE SCHEDULE," dated
12/08, and effective until 12/31/09,
2) and I acknowledge that I
have received, read, understand Joseph Kelly's "FEE SCHEDULE," dated 12/08,
and effective until 12/31/09.
(Mail, Fax, e-mail):
Kelly/ Patrick Ryan
Philadelphia, PA 19147
Joseph Kelly & Patrick Ryan