Head Start/EHS/Daycare Interview Questionnaire
Survey Completed By:
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First Name
Last Name
Client Information
:
Client Full Name
*
First Name
Last Name
Best Contact Number
*
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Area Code
Phone Number
E-mail
Questions and Details:
Is anyone sick in your house?
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Do you need any emergency supplies (food, medicine, thermometer, etc.)?
*
Do you need any other emergency assistance?
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Do you have crayons, books, scissors, etc. at home? If not, what do you need?
*
Can you access any of the free educational sites available online?
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Do you have a way to get what you need (car, neighbor, friend, family member)?
*
What can we do to help you?
*
Submit
Should be Empty: