Parents as Teachers Information Form
Thank you for your interest in our Parents as Teachers program.  Please answer the following questions to help us better serve you and your family.  
Sign in to Google to save your progress. Learn more
Child's Name
Gender
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Race
Clear selection
Ethnicity
Clear selection
Speaks English
Clear selection
Primary Language if not English
Parent/ Caregiver Name
Relationship to enrolled child
Address
Phone Number
Email address
Current Marital Status
Clear selection
What are you as a parent/ caregiver hoping to get out of the program? (Select all that apply)
Household Circumstances
My child/ family is experiencing homelessness
English is not the primary language spoken in our home
My child has a single parent/ caregiver
My child has refugee status
When my child was born, their parent/ caregiver did not have a high school diploma or GED
My child has a parent/ caregiver who is currently serving in the military away from home or has returned home from military duty within the last two years
I am a first time parent
Clear selection
I am currently under the age of 21
Clear selection
Developmental Delays and Special Needs
I am concerned about my child's development
My child has a documented disability or developmental delay
My child is experiencing behavioral issues
My child is blind or visually impaired
My child is deaf or hearing impaired
My child has been removed from child care or preschool for behavioral reasons
Benefit Eligibility
My child/ family is enrolled or eligible for Temporary Assistance for Needy Families (TANF)
My child is eligible for and received Supplemental Security Income (SSI)
My child is enrolled in or eligible for Medicaid
Clear selection
My child/ family is eligible for or enrolled in Supplemental Nutrition Assistance Program (SNAP)
My child is eligible for or receives free or reduced lunch
Clear selection
My child is eligible for IDEA Part B or Part C (early intervention, special education and related services)
Clear selection
I am pregnant or gave birth in the past year and am enrolled in or eligible for Medicaid
Clear selection
High Risk Pregnancy
When my child was born, their parent/ caregiver was under 20 years old
My child had low birth weight (under 5.5 lbs) with serious medical complications
Adoption/ Foster Care
My child is in foster care (I am my child's foster parent)
My child is adopted
Abuse/ Neglect
My child has been abused (this information is asked to help determine if your child may be eligible for some additional services and is optional to answer)
My child has been neglected (this information is asked to help determine if your child may be eligible for some additional services and is optional to answer)
Additional Optional Household Circumstances 
My child has experienced the death of a parent, caregiver, or sibling
Clear selection
My child's parent/ caregiver has a substance misuse issue
Clear selection
My child's parent/ caregiver has depression or another mental health condition
Clear selection
My child's parent/ caregiver has an intellectual disability
Clear selection
My child's parent caregiver has a physical disability or chronic health condition that limits the ability to parent
Clear selection
My child has been exposed to domestic violence within the family
Clear selection
My child has a parent that is or was incarcerated in federal or state prison or local jail, halfway house or is part of a bootcamp or weekend program requiring over night stays during the child's lifetime.  
Clear selection
My child has a parent/ caregiver who was born in another country and entered the U.S. within the last five years
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms