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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
/
DD
/
YYYY
Referred by:
*
Your answer
If you are referring a student, is the parent/guardian aware the referral is being made?
*
Your answer
Referring School Site (if applicable)
Your answer
Student ID #
*
Your answer
Student's Full Name
*
Your answer
Parent Name
*
Your answer
Phone
*
Your answer
Email
Your answer
Is student classified as McKinney-Vento or Foster?
McKinney-Vento
Foster
N/A
Clear selection
Is student receiving Behavioral Health Services? If so, include CID #.
Your answer
Medical Insurance Coverage
o
Check if the following apply to you
Medi-cal
Yes
No
Unknown
Clear selection
Medi-cal from Riverside County
Yes
No
Clear selection
How does recipient prefer to be contacted (ie. phone, email, letter)?
Your answer
Do you need assistance or would you like to receive resources in any of the following areas? (Please check all that apply.)
Adult Literacy Programs (ie. jTEP; Basic Computer Course)
Behavioral Health Services
Child Development/ Early Education- Social & Emotional Health and Special Needs
Donations- Clothing/shoes, school supplies and/or Hygiene Kits
Extracurricular Activities ( Soccer, Football, Baseball, Basketball, Volleyball, etc.)
Employment (Certificates: Food Handlers Card, etc.)
Food/ Nutrition
Health Care- Medical, Dental & Vision
Housing/Rental Assistance and Shelters
Legal Aid
Self-sufficiency programs ( CalWORKs, CalFresh, Child Care, Medi-Cal)
Transportation
Utility Assistance
Other:
Parent Support (Counseling, therapy and training/course )
At-risk/ Behavior
Domestic Violence
Mental Health
Anger Management
Parenting Classes (Triple P & Strengthening Families)
Other:
Provide a short description of family needs and background
*
Your answer
Is this a referral for Housing Assistance, Rental Assistance, Homelessness?
Yes
N/A
Clear selection
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