Family Needs Assessment

Financial & Legal
Personal Information

Family Needs Assessment

To what extent are the following resources adequate for you and your kin child(ren)?

FINANCIAL AND LEGAL

TO WHAT EXTENT......

1. Access to public assistance (for example, Medicaid, Temporary Assistance for Needy Families (TANF), Social Security) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

2. Money to buy necessities and pay bills *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

3. Support from social services and/or other government agencies *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

4. Clothing to stay warm and clean *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

5. Books, toys, and school supplies *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

6. Legal assistance related to being a kinship caregiver (for example, adoptions, legal custody, guardianship) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

7. Legal assistance related to public assistance (for example, Medicaid, Temporary Assistance for Needy Families (TANF), Social Security) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

8. Other legal assistance *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

NUTRITION

TO WHAT EXTENT......

9. Enough food for 2 meals daily for you and your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

10. Access to fresh fruits and vegetables *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

11. Ability to cook healthy meals *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

HOUSING

TO WHAT EXTENT......

12. Safe, livable housing *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

13. Indoor plumbing/water *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

14. Heating and/or, if needed, air conditioning *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

15. Lighting and electricity *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

16. Ability to complete home repairs or improvements *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

17. Ability to adapt my home for my kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

18. Telephone or access nearby to a phone *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

19. Internet or access nearby to internet *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

20. Furniture (for example, beds, cribs) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

CAREGIVER EMPLOYMENT AND SELF CARE

TO WHAT EXTENT......

21. A job that will support my household *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

22. Ability to expand my own education, skills & interests *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

23. Ability to do things for myself *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

24. Access to support groups or clubs *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

25. Ability to do fun things with my kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

26. Opportunities to learn how to be a more effective caregiver who is acting as a parent *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

TRANSPORTATION

TO WHAT EXTENT......

27. Ability to travel to places you need to go for yourself *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

28. Ability to transport your kin child(ren) to places, including appointments *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

HEALTH CARE

TO WHAT EXTENT......

29. Medical care for yourself *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

30. Medical care for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

31. Dental care for yourself *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

32. Dental care for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

33. Professional mental health counseling for yourself *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

34. Professional mental health counseling for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

35. Ability to plan for future health needs for yourself or your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

CHILDCARE/DAY CARE

TO WHAT EXTENT......

36. Management of the daily needs of your kin child(ren) at home *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

37. Babysitting for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

38. Routine childcare/day care for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

39. Full-time care for your kin child(ren) should something happen to me *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

CHILDREN"S EDUCATION

TO WHAT EXTENT......

40. K to 12 school enrollment for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

41. Early intervention and special education services for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

42. Payment for special needs of your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

43. Vocational training services of your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

44. Future educational options for your kin child(ren) (e.g. college) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

45. Ability to plan for a future job for your kin child(ren) *

0 Does Not Apply

1 Not At All Adequate

2 Seldom Adequate

3 Sometimes Adequate

4 Usually Adequate

5 Almost Always Adequate

This field is required.

46. Other supports needed? (write in)

This field is required.

0 characters / 0 words

PLACEMENT STABILITY & PERMANENCY MEASURES

TO WHAT EXTENT......

1. Is your kin child(ren) still in your home? *

Yes

This field is required.

2. Why did your kin child(ren) leave your home? *

Returned to birth parent

Entered foster care

Moved to another kin caregiver

Age 18 and older and left home

Other

This field is required.

TOP NEEDS

Find and maintaining housing

This field is required.

Concrete good (for example, furniture)

This field is required.

Daily food and nutrition

This field is required.

Public assistance

This field is required.

School related supports

This field is required.

Transportation

This field is required.

Primary medical care or resources

This field is required.

Dental care

This field is required.

Childcare/Day care

This field is required.

Mental health counseling

This field is required.

Kinship care support groups/networking

This field is required.

Education/training for kinship caregivers

This field is required.

Legal services and advice

This field is required.

Other

This field is required.

First Name *

This field is required.

Last Name *

This field is required.

Phone *

This field is required.

Today's Date *

This field is required.

I consent to Kinship Connections of Wyoming storing my submitted information so they can respond to my inquiry *

Please provide consent.

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