Family Anxiety Accommodation Assessment Form
Please complete this assessment to help us understand your family's needs regarding anxiety accommodations. Your responses will remain confidential and are used solely to guide support and resources.
Your Name
*
First Name
Last Name
Relationship to Family Member (e.g., Parent, Guardian, Sibling)
*
Which family member is this assessment about?
*
How often does anxiety impact your family member's daily activities?
*
1
2
3
4
5
Please indicate how much each area is affected by anxiety for your family member.
*
Rows
Not at all
A little
Somewhat
Quite a bit
Extremely
School/Work
1
2
3
4
5
Social interactions
6
7
8
9
10
Family routines
11
12
13
14
15
Sleep
16
17
18
19
20
Self-care
21
22
23
24
25
What types of accommodations are currently in place for your family member?
Flexible scheduling
Quiet space access
Extra time for tasks
Regular check-ins
Other
How effective are current accommodations in supporting your family member's needs?
*
Not effective
1
2
3
4
Highly effective
5
1 is Not effective, 5 is Highly effective
Are there any additional accommodations you believe would be helpful?
How comfortable does your family member feel discussing anxiety-related challenges at home?
*
1
2
3
4
5
Please share any specific concerns or additional information about your family's accommodation needs.
Submit Assessment
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