Assessment - Understanding Your Family and Adult Child's Current Situation & Needs

This brief survey is designed to help Shari Jonas understand the areas where you and your adult child are struggling and the challenges you’re all facing.

Your responses will allow Shari to assess how she can best serve you and will be discussed during your initial consultation call on zoom.

Once this assessment is submitted, you'll be directed to schedule a free 15-minute consultation.

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Name of Family Members (indicate which is your adult child's name)

Therapy: Has anyone in the family ever had therapy, coaching or counselling of any kind?

How old is your adult child? *

Describe their living situation *

Are they working, studying, or actively seeking employment? *

What does a typical day look like for your adult child?

How would you describe your relationship with your adult child right now? *

Do you have other adult children that are struggling or are they thriving? Please be as detailed as possible, including their ages and where they are living.

Mental Health: Has your adult child been diagnosed by a medical professional with any mental health issues, including neurodevelopmental issues? Please indicate. *

If they've been prescribed medication, please indicate the name and what does it treat? *

If there are prescriptions, is your adult child taking them regularly? Please be detailed in your response *

Have there been any recent episodes of emotional instability, aggression, or self-harm? If yes, please be specific. If no, just write no. *

Substance Abuse Addiction: Is your adult child struggling with alcohol, marijuana, cocaine, narcotics, etc? Please be specific with your response. If you're unsure whether or not it's an "addiction", please indicate the frequency that you see them using. *

Have they been through a substance abuse treatment program or are they currently in one? Please be specific. *

Have they ever relapsed? If yes, please indicate how often. If no, just write no. *

Behavioural Addiction: Does your adult child struggle with a behavioural addiction, such as video gaming, gambling, pornography, etc. Please be specific. If you are unsure, whether or not their behaviour is a problem, indicate how often you think they are actively engaged. *

Have they ever gone through a treatment program for their behavioral addiction or are they currently in one? If yes, please be specific. If no, just write no. *

Problems with the Law: Has your adult child ever had involvement with law enforcement or the legal system? If yes, please be specific. If no, just write no. *

Do you or any household members feel unsafe living with your adult child? Please be specific with your response. *

Which of the following areas do you feel the adult child is struggling with? You may check off as many answers as you wish. *

Struggles with Self Confidence

Has Difficulty Becoming Motivated

Doesn't Care About Their Responsibilities

Lacks Social Connections in Real Life (not online)

Unable to Problem Solve Without Someone's Help

Inability to Set Goals

Poor Time Management & Organizational Skills

Limited or Poor Money Management Skills

Other

In which areas do you feel the most frustrated with the young adult? You may check off as many answers as you wish. *

How long has the adult child been struggling, and what do you think contributed to it? *

What are the main behavioral obstacles preventing the adult child from becoming more independent? Check off as many as you wish. *

Lack of skills because of their education

Lack of work experience because they rarely get jobs

Lack of direction; they don't know what they want to do with their life.

Difficulty coping with pressure, stress, deadlines, responsibilities...

They are dependent on me or others for financial assistance

They have no desire to change their lifestyle

Other

How confident are you that the adult child can get through this? *

Very confident. I just need to know what to do

Somewhat confident. I've tried a lot of things but there must be more

Not very confident. I've tried everything, I'm not sure what else I can do

Zero confidence

Other

What efforts have been made so far for the adult child? *

They have seen a therapist

We have gone to family therapy together

I've taken a few courses, read books and tried to guide them on my own

Nothing, but I've been very patient & supportive, financially and emotionally

Not much as I don't know what to do

Other

Please ask your adult child if they would be interested in family therapy, alone with me, or neither?

They would see you alone

They would do family therapy

They're not interested in either

Other

Which of the following resources would be most helpful for you in guiding the adult child to an independent lifestyle? *

If I had one-on-one coaching (expert advice) to understand what I can do

If my adult child could have one-on-one coaching to help them.

If I could take an online course, that I can do on my own time

If I could join a support group with like-minded people, as in a facebook page

If I could get weekly tips and resources emailed to me in a Newsletter

Other

If we could wave a magic wand and get you the results you're seeking, what would those results look like? *

Is there anything else that you'd like to share with me? *

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Assessment - Understanding Your Family and Adult Child's Current Situation & Needs