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.
L
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:
TOPICS
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
Financial
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
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
