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Family Needs Assessment: Information

This document is a family needs assessment survey for a child's parents or guardians to complete. It lists various topics in different categories that families may need information or support on, including child development, family support, financial assistance, explaining the child's needs to others, child care, professional support, and community services. The form allows parents to indicate which topics they would like to discuss further with staff from the child's program. The information provided will be kept confidential.

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Renato Sanches
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161 views

Family Needs Assessment: Information

This document is a family needs assessment survey for a child's parents or guardians to complete. It lists various topics in different categories that families may need information or support on, including child development, family support, financial assistance, explaining the child's needs to others, child care, professional support, and community services. The form allows parents to indicate which topics they would like to discuss further with staff from the child's program. The information provided will be kept confidential.

Uploaded by

Renato Sanches
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Family Needs Assessment

Child’s Name: Person Completing Survey:

Date Completed: / / Relationship to Child:


Dear Parent:
Many families of young children have needs for information or 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. 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.
Would you like to discuss this topic
with a staff person from our
program?
Not
TOPICS No Sure Yes
Information
1. How children grow and develop
2. How to play or talk with my child
3. How to teach my child
4. How to handle my child’s behavior
5. Information about any condition or disability my child might have
6. Information about services that are presently available for my child
7. Information about the services my child might receive in the future

Family & Social Support


1. Talking with someone in my family about concerns
2. Having friends to talk to
3. Finding more time for myself
4. Helping my spouse accept any condition our child might have
5. Helping our family discuss problems and reach solutions
6. Helping our family support each other during difficult times
7. Deciding who will do household chores, child care, and other family tasks
8. Deciding on and doing family recreational activities

Financial
1. Paying for expenses such as food, housing, medical care, clothing, or
transportation
2. Getting any special equipment my child needs
3. Paying for therapy, day care, or other services my child needs
4. Counseling or help in getting a job
5. Paying for babysitting or respite care
6. Paying for toys that my child needs

Adapted from the Family Needs Survey. Donald B. Bailey, Jr. & Rune J. Simeonsson. FPG Child Development Institute, The University of North Carolina at Chapel Hill.
Would you like to discuss this topic
with a staff person from our
program?
Not
TOPICS No Sure Yes
Explaining to Others
1. Explaining my child’s condition to my parents or my spouse’s parents
2. Explaining my child’s condition to his or her siblings
3. Knowing how to respond when friends, neighbors, or strangers ask
questions about my child
4. Explaining my child’s condition to other children
5. Finding reading material about other families who have a child like mine

Child Care
1. Locating babysitters or respite care providers who are willing and able to
care for my child.
2. Locating a day care program or preschool for my child
3. Getting appropriate care for my child in a church or synagogue during
religious services

Professional Support
1. Meeting with a minister, priest, or rabbi
2. Meeting with a counselor (psychologist, social worker, psychiatrist)
3. More time to talk to my child’s teacher or therapist

Community Services
1. Meeting & talking with other parents who have a child like mine
2. Locating a doctor who understands me and my child’s needs
3. Locating a dentist who will see my child

Other: Please list other topics or provide any other information that you would like to discuss .

Is there a particular person with whom you would prefer to meet?

Thank you for your time.


We hope this form will be helpful to you in identifying the services that you feel are important.

Adapted from the Family Needs Survey. Donald B. Bailey, Jr. & Rune J. Simeonsson. FPG Child Development Institute, The University of North Carolina at Chapel
Hill. (Early Steps October 1, 2013)

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