Needs Assessment Form No auto multiply fields (in production)

Needs Assessment Form
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Date Survey Completed:

MonthDayYear
Date
How was the survey completed:

Completed in a face-to-face interview with participantCompleted over the phone with participant
Each section of the needs assessment is broken into 2 parts:

The turquoise columns are where you will indicate which services the participant has received in the last 12 months, services they currently receive, and services they may need in the future for themselves and/or the kinship child(ren).

The purple columns are assessing the frequency of services they've indicated they have used in the past 3 months or currently use.

Please check how frequently they needed help to get or keep this support. The scale is as follows:
- Never = 0
- Almost Never = 1 time
- Sometimes = 2 times
- Almost Always = 3 times
- Always = more than 3 times in the last three months

1. Financial support for necessities (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Rent
Utilities
Phone
Other Bills
Car Insurance
Car Repairs

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

2. Financial education support (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Taxes
Retirement
Budgeting

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

3. Help finding/maintaining housing (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Section 8
Tribal Housing
Shelter and Transitional Housing
Subsidies, vouchers, affordable housing
Eviction prevention
Housing with services
Shared housing
Housing repairs/ maintenance
Searching for housing (i.e. additional space, lower cost)

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

4. Support obtaining durable goods (i.e. bedding, furniture, clothing) (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Furniture
Linens (towels, bedding, etc)
Clothing
Appliances

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

5. Help getting enough food daily for your family

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Food bank
WIC
School lunch program
Food stamps, EBT, SNAP, etc.

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

6. Getting and keeping public assistance (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Medicaid
Medicare
Social Security (SSI)
TANF
Aged, Blind or Disabled (ABD)
Tribal Assistance Program

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.
Never = 0, Almost Never = 1 time, Sometimes = 2 times, Almost Always = 3 times, Always = more than 3 times in the last three months.

7. Help with transportation (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Bus/taxi pass
Gas Card
Rides to/from appointments

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

8. School related supports (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Preschool enrollment
K-12 enrollment
Special education services
Individual Education Plan (IEP)/504 plan
Educational Advocate
Tutoring

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

9. Help accessing primary care, other medical care or resources (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
For self
For kinship child(ren)
For other children/adults in the home

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

10. Help accessing dental care services (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
For self
For kinship child(ren)
For other children/adults in the home

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

11. Help accessing Traditional Healing or Traditional Medicine (Tribal Specific)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
For self
For kinship child(ren)
For other children/adults in the home

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

12. Childcare support (i.e. daycare, after school care, informal child care, etc.)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
For kinship child(ren)
For other children in the home

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.
Never = 0, Almost Never = 1 time, Sometimes = 2 times, Almost Always = 3 times, Always = more than 3 times in the last three months.

13. Respite: temporary, time-limited break for caregivers (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Respite for Caregivers
Respite Programs
Other respite voucher programs (e.g. Lifespan Respite)
Camps/retreats
Child/youth activities (e.g. extra-curricular activities, scouts, sports, etc.)
Family recreation activities

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

14. Referral to aging and disability resource center/I & A

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Select all that apply

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

15. Personal and emotional support about your circumstance, someone to talk to. (i.e. family, friend, neighbor, or community-based groups, etc.)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Select all that apply

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

16. Someone to talk to regarding your kinship child(ren) (i.e. family, friend, neighbor, community-based groups, etc.)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Select all that apply

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

17. Behavioral health/ counseling (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
For kinship child(ren)
Culturally relevant/holistic healing
Therapy/counseling
Substance use/recovery support

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

18. Behavioral health/counseling (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
For self
Culturally relevant/holistic healing
Therapy/counseling
Substance use/recovery support

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.
Never = 0, Almost Never = 1 time, Sometimes = 2 times, Almost Always = 3 times, Always = more than 3 times in the last three months.

19. Kinship care support groups/networking (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
For self
For kinship child(ren)/youth

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

20. Training for kinship caregivers (such as parenting classes and trainings)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Select all that apply

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

21. Language services (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Language classes (i.e. ESL classes)
Interpreter
Translation services

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

22. Access to legal services and advice (i.e. legal representation, custody, estate planning/end of life, child support, etc.)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Select all that apply

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.

23. In-home family services (Select all that apply)

	Used in past 12 months	Currently use	Don’t currently use, but need	Don’t need at this time	Never	Almost never	Sometimes	Almost always	Always
Rides to/from appointments
Home-visiting programs
Family preservation
In-home services
Birth to 3/early intervention

Service Type, Organization Name, Phone, Address, Contact. Please add all applicable business types.
Other services, please fill in as appropriate, and apply the time tables as above.
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