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
can be planned.
Use additional paper.
Date,
Your name,
Address,
City, State,
Zip,
Country,
Phone numbers,
Fax number,
E-mail:
What is your relationship to
the group member?
Who referred you?
Please include a recent photo
of 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? 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 the 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 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?
