Template library · Assessments & screeners
Family & Social History template
Gather detailed family structure and social support information.
Detailed family and social history component
- 13 fields across 3 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Family & Social History
- Family of origin structure and relationshipsText
- Family mental health / substance use historyText
- Current household compositionText
- Quality and availability of social supportText
- Significant losses or disruptionsText
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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