A Village for Moms Foundation
Village Assessment & Success Plan
Because Every Mom Deserves a Village.
Thank you for trusting A Village for Moms Foundation. This assessment helps us understand your family's needs so we can support you through resources, education, and ongoing encouragement. Our goal is to walk alongside you—not just meet immediate needs, but help you build a stronger future for yourself and your family.
Personal Information
Full Name:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Address:
Preferred Contact:
Emergency Contact:
Household Information
Adults in Household:
Children:
Children's Ages:
Currently Pregnant?
Yes
No
Due Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Tell Us About Your Journey
What are you most proud of as a mother?
What is your biggest challenge right now?
If you could change one thing about your current situation, what would it be?
Immediate Needs
Please tell us about the immediate needs you and your family are experiencing today
Employment & Career
Employment:
Full-Time
Part-Time
Unemployed
Student
Stay-at-Home Parent
Interested in:
Better Job
Resume Help
Interview Coaching
Transportation
Education
GED
College
Trade School
Certifications
Financial Literacy
Parenting Classes
Breastfeeding Education
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Financial Wellness
Know your credit score?
Yes
No
Credit Education
Budgeting
Debt Management
Homeownership Information
Childcare
Daycare
After-School Care
Childcare Assistance
Parenting Support
Health & Wellness
Breastfeeding Support
Mental Health
Building Your Village
If one person could make your life easier right now, what would they help you with?
What is one goal you'd like to accomplish within the next six months?
What does success look like for you and your family?
Your Village Plan (Completed Together)
Immediate Needs:
Goals:
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3.
4.
5.
6.
7.
Follow-Up Plan
Preferred Follow-Up:
Phone
Text
Email
In Person
What days and times are you generally available for your initial Village Meeting?
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Other
Preferred Time
Morning (9AM-12 PM)
Afternoon (12PM-4PM)
Evening (4PM-6PM)
Other
Meeting Preference
In Person
Phone
Virtual
Other
Celebrate Progress
Celebrate Progress Options
Obtained Employment
Resume Completed
Improved Credit
Found Childcare
Enrolled in School
Reached Personal Goal
Other:
Staff Notes
Staff Notes
Village Mom ID:
Assessment Completed By:
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Should be Empty: