Many families of young children have needs for information or support. If you wish, our staff is very willing to discuss these needs with
you and work with you to identify resources that might be helpful.
isted below are some needs commonly expressed by families. The columns on the right will be used to check any topics you would like
to discuss. At the end there is a place that may be used to describe other topics not included in the list. The information you provide
through this form will be kept confidential.
Family Needs Assessment
Type YES if you would like to discuss this topic with a staff person from our program.
Child’s Name: Person Completing Survey:
Date Completed: Relationship to Child:
Address: Phone Number:
Family & Social Support
1. Getting along in your family
2. Having friends to talk to
3. Finding more time for myself (Time Management)
4. Parenting a Challenging Child or Child with Special Needs
5. Single Parenting or Blended Families
1. Developing a Budget
2. Information on Food Pantries
3. Transportation Concerns
4. Finding Employment
5. Finding Housing: Rental Assistance, Home Ownership,
6. Home Energy Assistance/Weatherization
7. Daycare Assistance/Finding Childcare
8. Medical Assistance/Food Snap
Community Support
1. Scheduling an appointment with Mental Health Counselor
(ADHD, Stress, Depression, Anxiety, Grief, Marital Concerns, Ect)
2. Scheduling an appointment with Alcohol /Drug Counselor
3. Obtaining GED or College Classes (Financial Aid Process)
4. Writing a Resume
5. Locating a Dentist or Medical Doctor:
6. Domestic Violence Support/Education
More on the back
Would you like to discuss this
topic with a staff person from
our program?
Educational Material or Training
1. Weight & Diet Control Information
2. Bedtime Struggles
3. Potty Training and Concerns
4. Children and Routine
5. Children and Responsibility
6. Children’s Development Milestone
7. Positive Behavior/Discipline Techniques
8. Sibling Rivalry
9. Cooking on a Budget
10. Importance of Play
11. Parent Support Groups
12. Handling Transition
13. Household Chores
1. Food
2. Shelter/Housing
3. Medical
Other: Please list other topics or provide any other information that you would like to discuss.
Thank you for your time.
We hope this form will be helpful to you in identifying the services that you feel are important.