Kinship Caregiver Demographics Child
This form includes demographic information regarding the child in their care.
Caregiver's Name
First Name
Last Name
1. Please provide information on the kinship child(ren) (under 18) currently living in your home
First Name
Middle Name
Last Name
2. Gender
Male
Female
2-Spirited
Other
3. Birthdate
-
Month
-
Day
Year
Date
4. Race/Ethnicity (check all that apply)
American Indian/ Alaskan Native
Multiracial American Indian Native (any American Indian/Alaska Native indicated as well as another race)
Black or African American
Multiracial Black (any Black indicated as well as another race except American Indian/Alaska Native)
Hispanic or Latino/Latinx
Asian/Pacific Islander
White (Non-Hispanic)
Multiracial (all other combinations, with no indication of American Indian/Alaska Native or Black)
Unknown (no races indicated)
Other
Tribal Affiliation if applicable
5. Time Kinship child has been in your care:
6. Have you been caring for the kinship child continuously?
Yes
No
Intermittently
7. What is your relationship to the kinship child?
Grandparent
Sibling
Aunt/Uncle
Foster parent
Adoptive parent
Non-Relative
Other
8. Relationship of the kinship child to other children in the home
Sibling
Cousin
Family friend
Niece/Nephew
No other child(ren) in the home
Other
9. Please indicate the reason(s) your kinship child came to be in your care: (select all that apply)
Age of parent
Parental incarceration
Death of parent
Parental financial circumstance
Incident of child abuse/neglect
Childs injury
Parental substance abuse
Parental behavioral health
Deportation
Parent left community for work/school
Parental physical health
Military services
Other
10. Please select the option that best describes your role:
Informal *Defined as kinship care provided without involvement with CYFD/CPS or formal child welfare system *if selected, proceed to question 11. Do not answer questions 12 & 13.
Formal *To be a formal kinship provider, your kinship child had to be placed in your home because of a CYFD/CPS investigation or involvement with the child welfare system. *If selected, answer questions 12 & 13.
11. If you are caring for your kinship child through an informal arrangement, please indicate if any of these arrangements apply to your situation. (check all that apply)
Parental Consent Agreement
Durable Power of Attorney
Informal arrangement (no paperwork)
Family decision
Health Care Consent Waiver
Non-parental custody (sometimes referred to as third-party custody)
Other
12. If your kinship child was placed in your home with the involvement of Child Welfare (Tribal or otherwise) and the court, did you choose to be licensed? (Please answer yes if you were a licensed foster parent before the child’s placement)
No
Yes
If yes, name of Child Welfare agency:
13. Please identify if you have completed one of these permanent plans for your kinship child.
Adoption (includes customary adoption)
Guardianship
Non-parental custody (sometimes referred to as third-party custody)
Other, please specify
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14 A. Since the date of your first needs assessment, has your child entered foster care? If Yes Enter date below.
/
Month
/
Day
Year
Date
14 B. Date of first needs assessment
/
Month
/
Day
Year
Date
15. In general, how would you rate your kinship child’s physical health?
Excellent
Very Good
Good
Fair
Poor
16. In general, how would you rate your kinship child’s behavioral health?
Excellent
Very Good
Good
Fair
Poor
17. Does your kinship child have a primary care physician or clinic?
Yes
No
18. Does your kinship child(ren) receive their medical care at an IHS clinic or tribal clinic? (Tribal Specific)
Yes
No
19.Does your kinship child have a diagnosed physical health issue?
Yes
No
Not Applicable
I don’t know
Diagnosis
20. Does your kinship child have a diagnosed behavioral health issue?
Yes
No
Not Applicable
I don’t know
Diagnosis
21. Are your kinship child’s physical health needs being met?
Yes
No
Not Applicable
I don’t know
22. Are your kinship child’s behavioral health needs taken care of?
Yes
No
Not Applicable
I don’t know
23. Is the child in your care pregnant or parenting youth also in an informal kinship relationship?
Yes
No
Not Applicable
I don’t know
24. Has your kinship child attended their well-child visits since they came to live with you?
Yes
No
Not Applicable
I don’t know
25. If the kinship child required an emergency room visit in the last 6 months, what were the reasons for the ER visit(s)? (Check all that apply)
Upper respiratory infections
Headaches, including migraines
Allergic reactions
Otitis media and related conditions
Skin and subcutaneous tissue infections
Sprains and strains
Fever of unknown origin
Viral infections
Open wounds of head, neck and trunk
Abdominal pain
Nausea and vomiting
Fracture of upper limb
Acute bronchitis
26. In the last 6 months, how many ER visits has your kinship child had? Number of visits or I don't know.
27. What type of health insurance does your kinship child have? (Select all that apply)
Medicaid
Employer-based
No Insurance
Tribally Supported Insurance Plan
Not Applicable
Other, please explain:
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28. Kinship Child Education (If more than one child, please complete one for each child)
Does your kinship child attend an early childhood program or schools?
Yes
No
If yes, what is your kinship child’s grade?
29. Has your kinship child repeated any grades?
Yes
No
I don't know
30. Does your kinship child receive special education services or other support programs?
Yes
No (skip to next)
I don’t know
31. Does your kinship child have a current IEP or 504 plan?
Yes
No
I don't know
32. Is your kinship child failing any classes?
Yes
No
I don't know
33. Do you need assistance to address your kinship child’s social or behavioral needs at school?
Yes
No
34. Do you need assistance to request academic support for your kinship child?
Yes
No
35. Has your kinship child been suspended or expelled? (Check all that apply)
Yes, suspended
Yes, expelled
No
I don't know
How many absences has your kinship child had in the last year?
None
Number of absences
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