Form - Parent to Parent of Miami

Intake Form

Please take a few minutes to complete the forms below so we can assign you properly to an Education and Support Specialist. Thank you.

Date

Month

Day

Year

I amParent/CaregiverOther

if Other

Referred by

First Name

Last Name

GenderFemaleMale

Date of birth

Month

Day

Year

EthnicityHispanicHaitianOther

if Other

Employed by

Country of origin

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

Phone Number

Type

Total number of children in your care

Are you proficient in English?YesNo

Languages spoken in the homeEnglishSpanishCreoleOther

if Other

Child/adult information

First Name

Middle Name

Last Name

Date of Birth

Month

Day

Year

Age

GenderMaleFemale

EthnicityHispanicHaitianOther

if Other

School/Center

Grade

School Placement/Type of Class

Disability/Condition

Concerns

Family Outcome Survey – Initial

Instructions:

Section A of the Family Outcomes Survey focuses on the ways in which you support your child’s needs. For each statement below, please select which option best describes your family right now: not at all, a little, somewhat, almost, or completely.

Outcome 1: Understanding your child’s strengths, needs, and abilities

Outcome 2: Knowing your rights and advocating for your child

Outcome 3: Helping your child develop and learn

Outcome 4: Having support systems

Outcome 5: Accessing the community

Parental Stress Scale – Initial

Instructions:

The following statements describe feelings and perceptions about the experience of being a parent. Think of each of the items in terms of how your relationship with your child or children typically is.

Please indicate the degree to which you agree or disagree with the following items.

Parent/Caregiver Registration Form

Intake Form