Family Information Form                            Please complete this form and submit.             Note that you are not guaranteed a spot until you have received a response from PC+ of the North Shore.    
      The purpose of the Family Information Form is to collect self-reported contact and demographic data from each program family. All data collected will be entered into ParentChild+’s management information system, DAISY.                          
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Email *
How did you hear about the Parent Child Plus program? *
Child's First Name  *
Child's last name *
Provide the address of the location where the visits will take place.
 *
City  *
State  *
Zip Code  *
County *
Email  *
3. Provide the phone number  that is best to reach the family.
 *
Participant Child: Demographics
4. What is the date of birth of the child?
 *
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5. To which gender identity does the child most identify?
 *
6. Does the child identify as Hispanic and/or Latino?*
 *
 7. If question #6 answer is yes, select from the categories and sub-categories*
 *
 Venezuelan Other Hispanic and/or Latino and another race
 *
 8. If question #6 answer is no, which race does the child identify as? 
 *
Participant Adult: Demographics 
How many adults will be participating in visits? 
First name of adult attending  *
Last name of adult attending  *
. What is the date of birth of the adult 
 *
MM
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DD
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To which gender identity does the adult most identify?  *
What is the adult's relationship to the child? *
Was the adult born in the United States?  *
If answer to question 14 is no, answer the below questions:  *
Does the adult identifies as Hispanic and/or Latino  *
if the answer was yes, select from the cathegories and sub-cathegories
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Hispanic and/or Latino and another race 
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 If the answer before is no, which race does the adult identify as? Select from the categories 
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Does the adult speak English? 


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Does the adult write in English?
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22. Does the adult read in English? 


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What is the adult’s highest level of education completed?* 

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Is the adult currently enrolled in a school or educational program?*
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What is the adult’s employment status?*
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If adult is employed, what job industry does the adult work in?* 


Was the adult 19 years old or younger when their child was born?
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Is the adult a single parent?*
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Has the adult served in the military?
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Please provide the following information on the other people who live in the household with  the participant child.
Number of other adults:
Number of siblings and/or other children:
Of the siblings and/or other children who live in the household, how many will be  participating in visits?
What is the family’s household composition?
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Is the family homeless?

Homeless is defined as an individual who lacks housing (without regard to whether the  individual is a member of a family), including an individual whose primary residence during  the night is a supervised public or private facility (e.g. shelters) that provides temporary living  accommodations, and an individual who is a resident in transitional housing (i.e. family who  lives doubled up with another family. 


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 How long has the family lived at the current residence?
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What language(s) are spoken in the home?
What is the annual household income?
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Does the family or program child receive government aid? Select all that apply
Has the child been medically diagnosed with a developmental delay or disability?
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f question #38 is yes, has the child received support services/therapies for the  developmental delay or disability?
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If question #39 is yes, which of the following developmental delays or disabilities has the  child received support services/therapies for? Select all that apply
If question #39 is no, what was the primary reason the child did not receive support  services/therapies for the developmental delay or disability?
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Has the child been medically diagnosed with a chronic health condition?
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If question #42 is yes, has the child received medical treatment for chronic health  condition(s)?
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If question #43 is yes, which of the following has the child received medical treatment for?
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If questions #43 is no, what was the primary reason the child did not receive medical  treatment for the chronic health condition(s)?
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Was the child low birth weight (below 2,500kg or 5lbs 8oz)?
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Was the child born prematurely (before 37 gestational weeks)?
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Did the mother receive prenatal care during pregnancy?
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 Is the participant child up-to-date with their well-child visits?* 

For our participant children, well-child visits should be completed at 18 months, 24 months, 30  months, 3 years old and 4 years old.  

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Has the participant child had continuous healthcare coverage for the past 6 months?
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Has the participant adult had continuous healthcare coverage for the past 6 months?* If there are more than one participating adult and their coverage differs, please answer  question for the adult who participates in most visits. 


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Have other household members had continuous healthcare coverage for the past 6 months? 
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Has the participant child and/or adult previously received any of the services below? Select  all that apply*.

Is the participant child and/or adult currently receiving any of the services below? Select all  that apply*.

Program information (Office use only)
Date of intake*:
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Date of first visit:
MM
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A copy of your responses will be emailed to the address you provided.
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