HOPES/HIP General Intake and Assessment

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Lives in a stable environmentStaying in a temporary shelter (e.g. a shelter, mission, motel)Staying with friends or family on a temporary basisLiving with parentsLiving in public housingLives in a foster care environmentLives on the street, in a car, park, or unstable situationOther:

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EnglishSpanishOther(list):

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CHILD DEMOGRAPHIC and PERSONAL INFORMATION. We require the following information for the purposes of helping our staff use the most respectful language when addressing your child, understanding our population better, and fulfilling our grant reporting requirements. The options for some of these questions were provided by our funders. Please help us serve you better by selecting the best answers to these questions. Thank you.

MaleFemaleIntersexNo Answer

Non-Hispanic/LatinoHispanic/Latino

5.8 Accessibility Needs (select all that apply):

Deaf:Hard of Hearing

Visual Impairment:Legally BlindBlind

Require ramps/automatic doorsRequire accessible deskRequire accessible chair

Licensed Day CareCertified Pre-KElementary SchoolOther: (Please List)

Less than kindergartenKindergartenFirst Grade

Non-Hispanic/LatinoHispanic/Latino

MaleFemaleIntersexNo answer

Often trueSometimes trueNever true

NoYesAlready shut off

Not well at allNot very wellA little bit wellVery well

Not at allSeveral daysMore than half the daysNearly every day

	Monday	Tuesday	Wednesday	Thursday	Friday
Morning	2	3	4	5	6
Afternoon	7	8	9	10	11

I have been provided information on the referenced Prevention and Early Intervention Program and wish to receive services. I understand that data on my child/youth/family will be collected, maintained, and entered into a secure database. The information will be utilized to track services for evaluation purposes and to ensure quality services are being provided. I hereby authorize my child/youth/family to participate in the program.

BCFS Health and Human Services Community Services Division

HOPES/HIP General Intake and Assessment

CHILD GENERAL INFORMATION

PRIMARY PARTICIPATING CAREGIVER GENERAL INFORMATION

HOUSEHOLD INFORMATION

EMERGENCY CONTACT

PRESENTING CONCERN:

CHILD'S EDUCATION

CHILD'S DISABILITY STATUS

PARTICIPATING CAREGIVER INFORMATION (1)

NEEDS SURVEY:

Over the last two weeks how often have you been bothered by any of the following problems?

PREFERENCES: