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FAMILY NEEDS ASSESSMENT

A family needs scale assists the Tewa Roots staff in supporting families. Many families have needs for information about resources or direct support. If you wish, our staff are very willing to discuss these needs with you and work with you to identify resources that might be helpful. Listed below are some needs commonly expressed by families. Read the following statements and choose the option that best describes your need for support regarding each area and add any details that would be helpful for us to know. 


Below the family needs assessment is the mental health assessment: This brief form will let us know about any mental health concerns you have about your child so that we can better work with them to support them. Please complete this form with them if possible, or have them complete it themselves. Below are examples of problems that people sometimes have. Please check whether each is NEVER true, SOMETIMES true, or OFTEN true for your child. When considering these questions please keep in mind what is typical for them. If you have noticed significant changes in the past 3-6 months in these areas choose the last box in addition to Never, Sometimes, or Always.


GROUP CONSENT


Understanding therapeutic group processing at Tewa Roots Society

Therapeutic group processing can help you understand more about yourself and others in a safe environment. Tewa Roots Society Basecamp groups will use creative methods to explore building emotional regulation and coping skills, and expressing and processing emotions through art based activities, movement and breathwork, and other activities. We will explore topics together such as healthy relationships, communication skills, anger management, and building identity and resiliency. Group members will not be forced to share more than they are comfortable with, and will learn ways to support each other through difficult times. If at any time you feel uncomfortable or unsafe in the group, please let one of your facilitators know. Your facilitators are there to create a safe space and support you. Knowing the risks of group processing, there can be discomfort involved in participating in group processing. You may remember unpleasant events, or experience feelings of anger, fear, anxiety, sadness, frustration, loneliness, helplessness, or other unpleasant feelings. If these distressing emotions arise during your therapy, please talk with your group and with your group facilitator. 


Group Member’s Agreement for Confidentiality 

All members of the group will be asked to agree to a high level of confidentiality in the group sessions. It is appropriate to share your personal reaction and feelings about the group with others, but we do not tolerate the sharing of other people’s stories with anyone outside of the group.


Confidentiality and Limitations

Confidentiality of information conveyed in groups is highly important and honored by all personnel at Tewa Roots Society. Certain legal and ethical limitations to confidentiality must be acknowledged and addressed. Staff at Tewa Roots Society are expected to consult with other professionals regarding the group and/or seek supervision. Your information may be disclosed to third-party payers only when you have authorized such disclosure, such as paying for services through an insurance company. State law mandates the reporting of any suspected abuse or neglect of children or vulnerable adults. Mandatory reporting is also required for situations in which a client is at risk of ending their own life or the life of somebody else along with the disclosure of abuse of a minor, elder, or person with a disability. Mental health records may be legally subpoenaed, in which case a judge could require Tewa Roots Society to release client information. You may also request records be shared with other healthcare providers for coordination of care. This would require you to sign a release of information form. Provision of records may take up to 30 days.


“I have read, understood, agree to, and consent to the conditions of joining a Tewa Roots Society group outlined in this group consent form.”



First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Needs Assessment, Do you family need help with any of the following:
Having enough money to pay bills and buy necessities*
No support needed
Some support would be helpful
Support is needed
Having a safe and secure place to live*
No support needed
Some support would be helpful
Support needed
Access to clean water*
No support needed
Some support would be helpful
Support needed
Having working plumbing, lighting, and/or heat*
No support needed
Some support would be helpful
Support Needed
Having enough food on hand for at least two meals for my family*
No support needed
Some support would be helpful
Support needed
Paying for the special needs of my child (ex. Medicines, healthcare needs, etc.)*
No support needed
Some support would be helpful
Support Needed
Getting places I need to go (transportation)*
No support needed
Some support would be helpful
Support needed
Establishing a general sense of safety in the home (physical and emotional)*
No support needed
Some support would be helpful
Support needed
Attaining school supplies*
No support needed
Some support would be helpful
Support Needed
Help obtaining an IEP for your child at school*
No support needed
Some support would be helpful
Support needed
Desire to connect more with my family's Indigenous cultures and practices*
No support needed
Some support would be helpful
Support needed
Applying for Medicaid or other insurance provider*
No support needed
Some support would be helpful
Support Needed
MENTAL HEALTH INFORMATION - Has your youth experienced any of the following:
Inability to Fall or Stay Asleep*
Never
Sometimes
Often
Significant changes in the past 3-6 months
Experiences Nightmares*
Never
Sometimes
Often
Significant changes in the past 3-6 months
Oversleeping/Difficulties Getting out of Bed*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Feeling Anxious*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Excessive Worry About Future *
Never
Sometimes
Often
Significant changes in the last 3-6 months
Difficulties in School*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Changes in Eating Patterns *
Never
Sometimes
Often
Significant changes in the last 3-6 months
Difficulty Concentrating/Easily Distracted*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Skipping Meals*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Impulsive, Act Without Thinking*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Lack of Interest in Preferred Activities*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Expressed Thoughts of Self Harm*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Engaged in Physical or Verbal Fights*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Noticeable Mood Swings (Rapid Change from one Emotion to Another)*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Been Involved in Gang Activity to your Knowledge*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Expressed Thoughts of Harming Others*
Never
Sometimes
Often
Significant changes in the last 3-6 months
Youth has experienced a change of housing *
No
Yes
Youth has experienced change of school*
No
Yes
Youth has experienced parent separation*
No
Yes
Youth has experienced change in social group *
No
Yes
Youth has experienced death of family member/friend/pet *
No
Yes
Other significant events that may have left a traumatic impact:
Does your youth have any health concerns? If yes, please explain:
Is your youth taking any medications?If yes, what kind?
Has your youth ever had a serious accident/illness or hospitalization? If yes, please explain:
Does your youth use any substances to your knowledge? If yes, which ones:
Has your youth ever been seen by a counselor/therapist before? If yes, where and when?
Do you have any other concerns?
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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