World of Wonders: Family Needs Survey
One of our goals at WOW is to make sure that every family who needs assistance receives the proper referrals to help their family. Please fill out this form and we will send you resources or agencies to contact in order to receive support. This form will remain confidential.
Child's/Children's Name(s)
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Person Completing This form:
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Date Completed:
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Child Development and Education: Does anyone in your family have any need for resources or support in the areas listed below?
Information on child growth and development
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Yes
No
Guiding and supporting a child's behavior
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Yes
No
Obtaining toys or activities
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Yes
No
Preparing your child for kindergarten
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Yes
No
Please briefly list any Child Development and Education Concerns you have:
Child and Family Health: Does anyone in your family have need for resources or support in the areas listed below?
Health insurance and/or access to regular medical/dental care
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Yes
No
Accessing immunizations
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Yes
No
Finding pediatricians, therapists, or other medical professionals.
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Yes
No
Concerns with depression, anger, anxiety, or mental health needs.
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Yes
No
Concerns with alcohol, drug, or addition problems
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Yes
No
Please briefly list any Child and Family healthy concerns you have:
Financial and Household Supports: Does anyone in your family have need for resources or support in the area below?
Helping pay for childcare.
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Yes
No
Help finding housing or safe housing
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Yes
No
Help with food expenses
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Yes
No
Finding household items such as furniture, clothing, or school supplies.
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Yes
No
Attending school (such as a GED, Verification, or college degree)
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Yes
No
Helping Find work or job training
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Yes
No
Please list any financial and household supports that your family needs assistance with:
Are there any needs you or your family have that are not listed above:
Parent Signature
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Date
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Month
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Day
Year
Date
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