FAMILY CONSTELLATION (Include all persons named above.

For all persons mentioned here and

throughout the workbook be as specific as possible about their relationship(s) to the child, e.g maternal
grandmother, half-sibling through mother, step-parent,)

Name Relationship HH* %H1 %H2 Age Ethnicity Grade/Work

CLIENT Self 100 12 Anglo-American 6th
Jane Gilbert Mother 1 100 35 Anglo-American Manager
Sara Johnson Sister 100 15 Anglo-American 10th
Henry Gilbert Stepfather 2 0 100 41 Anglo-American Own business
George Johnson Bio Father 3 0 40 Anglo-American Unknown
*In column HH put a 1 for the Head of Household 1, a 2 for the Head of Household 2, etc. Put 0 if not Head
of House Hould. In column %H1 put the % of time each individual spends in Household 1, Repeat for time spent in
Household 2.

INTAKE & ASSESSMENT CONTACT RECORD

DATE PERSON (S) TASK COMPLETED PERSON(S) TIME

ATTENDING COMPLETING SPENT
9/20/07 (Physician report Reviewed record of medical Ammen 0.50 hr
& psychiatrist exam completed 6/07 &
report) physchiatric exam completed
8/07
9/20/07 (Language report) Reviewed records of language, Ammen 0.25 hr
speech & hearing evaluation
completed 6/07
9/20/07 (Educational Reviewed records of cognitive Ammen 0.25 hr
psychologist and educational evaluation
report) completed 6/07
9/28/07 Mother Ecosystemic History, DTORF Ammen 1.0 hr
9/28/07 Mother & Client Dyadic Interview Ammen 0.5 hr
9/28/07 Client Play Interview Ammen 1.0 hr
9/28/07 Mother PIC2;PSI-SF,BRIEF (while client Ammen 1.0 hr
was in play interview)
10/5/07 Client Psychological Testing Ammen 2.0 hr
10/6/07 Teacher Phone Interview Ammen 0.5 hr
10/12/07 Mother, Client, Family Interview Ammen 1.5 hr
Sister, Stepfather