Family Needs Assessment
Parent Involvement and Community Outreach (P.I.C.O) would like to help meet the needs of the children and families we serve. Please complete the following so that we may best serve you.
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Date *
MM
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DD
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YYYY
Referred by: *
If you are referring a student, is the parent/guardian aware the referral is being made? *
Referring School Site (if applicable)
Student ID # *
Parent Name *
Phone *
Email
Is student receiving Behavioral Health Services?  If so, include CID #.
Medical Insurance Coverage
o Check if the following apply to you
Medi-cal *
Medi-cal ID
Medi-cal Issue date
MM
/
DD
/
YYYY
Medi-cal from Riverside County
Clear selection
How does recipient prefer to be contacted (ie. phone, email, letter)?
Do you need assistance or would you like to receive resources in any of the following areas? (Please check all that apply.)
Parent Support (Counseling, therapy and training/course )
Provide a short description of family needs and background *
Submit
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