Fillable FAMILY ASSESSMENT Initial Annual

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FAMILY ASSESSMENT Initial Annual

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Country of origin: US
File type: PDF

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SCDHHS/IDEA PART C/01JUL20/VOIDS ALL PREVIOUS VERSIONS
FAMILY ASSESSMENT FORM: TEMPORARY
FAMILY ASSESSMENT
☐
Initial
☐
Annual
SECTION 1: GENERAL INFORMATION AND CONSENT
Child’s First and Last Name:
DOB:
BRIDGES ID:
Service Coordinator Name:
Date Family Assessment completed:
initials:
SECTION 2: PRIORITIES AND CONCERNS FOR MY CHILD (CHECK ALL THAT APPLY):
I have questions about or want help for my child in the following areas
(check all that apply):
Family’s remarks regarding concerns identified about their child (including
any not listed):
☐
Moving around (crawling, scooting, rolling, walking)
☐
Ability to maintain positions for play
☐
Talking and listening
☐
Thinking, learning, playing with toys
☐
Feeding, eating, nutrition
☐
Having fun with other children; getting along
☐
Behaviors/appropriate interactions
☐
Expressing feelings
☐
Toileting; getting dressed; bedtime; other daily routines
☐
Helping my child calm down, quiet down
☐
Pain or discomfort
☐
Other:
SECTION 3: PRIORITIES AND CONCERNS FOR ME AND MY FAMILY (CHECK ALL THAT APPLY):
I have questions about or want help for me or my family in the following
areas (check all that apply):
Family’s remarks regarding identified priorities of the family (including any
not listed):
☐
Learning more about how to help my child grow and develop
☐
Finding or working with doctors or other specialists
☐
Learning how different services work or how they could work better for
my family
☐
Planning for the future; what to expect
☐
Parenting skills
☐
People who can help me at home or care for my child so I/we can have a
break; respite
☐
Childcare
☐
Housing, clothing, jobs, food, or telephone
☐
Information on my child’s special needs, and what it means
☐
Ideas for brothers, sisters, friends, extended family
☐
Money for extra costs of my child’s special needs
Linking with a parent network to meet other families, or share
☐
Parent Training and Information Center
☐
Parent-to-Parent Support
☐
SCDHEC/CSHCN
☐
Other:
SECTION 4: STRENGTHS AND RESOURCES
Strengths and resources that our family has to meet our child’s needs. For example, relatives nearby, support from friends, work friends.
SECTION 5: FAMILY HOME AND COMMUNITY ROUTINES AND ACTIVITIES
Typical activities we do with our child, or we do as a family (include routine things like dressing, bathing, meals, story time etc., as well as things you do in your community
(for example, shopping, visiting friends or relatives, trips to the library, etc.)).
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FAMILY ASSESSMENT Initial Annual

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Completed 9 March 2022

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