Parent #1 *
Names of any other adults living in the home and relationship to Parent #1 Address
* Email *
Cell Phone Home Phone Assessment Type
Is this your first assessment? Then select "Initial Intake."
If you have filled this out before but have a new need, please select "Emergent Need."
If you are providing us with new information after receiving a notice, please select "Annual Follow-up."
Caregiver Role *
Which descriptions best fit your caregiving role (select all that apply)
Current Foster Parent Current Adoptive Parent Current Kinship Parent Prospective (fost/adopt/kin) Parent Former (fost/adopt/kin) Parent Other (make note below) Caregiver Role Note
If "Other" was selected above
Name, Ages and Gender of Children Currently in Care *
Please note if Foster (F), Adopted (A), Kinship (K), or Biological (B)
How long have you been providing (or did provide) care?
Agency Affiliation or Participation
(FFA, county, etc.)
Section Break Interview Questions
Please fill out these questions so we can best support you through our program
Best Support Received (not RESPITE/OC United) *
What are the best ways that you have been supported in your journey either by agencies or groups? (i.e., various trainings, childcare services, meals, etc.):
Satisfaction with Support Received (not RESPITE/OC United) * Best Support Received from RESPITE/OC United *
How have we helped you? (if applicable)
Satisfaction with Support Received (RESPITE/OC United) * What are some ways that you WISH you would have been supported? * Current Support System *
Mark all that apply. If "other" is selected, please make note
Agency Faith Community Family Friends Other Current Support System Note
If you selected "other," please make note here
True or False: I have people I can count on * Satisfaction with Support from Other Individuals * True or False: I can recognize and cope with stress * True or False: I would like to receive help with coping with stress * True or False: I have a Self-Care/Wellness Routine * Satisfaction with Self-Care/Wellness Routine * True or False: I can identify spiritual practices that feel supportive * Satisfied by my level of spiritual practices * What is your Overall Level of Self-Worth * What are the current challenges your child is facing? * What are the current challenges YOU are facing? * If granted 30 minutes of freetime, how would you utilize it? * If we were to send a helper to your home for an hour, with what could they provide help? * Self-Identified Needs *
Please mark all that apply. If you select "Other," please add note in the space below.
Care Community Parent Trainings Support Groups Grief and Loss Support Trans-racial or Cultural Support Attachment Training Fost/Adopt/Kin Community Connection Educational Support (IEP, 504, advocacy) Self-Care & Wellness Opportunities Mentorship (Parent) Mentorship (Child) Sensory Items (i.e., weighted blankets, shaker bottles, etc.) Other Identified Needs Note
If you selected "Other" above, please add note here.
Would you like to join our mailing list? *
Would you be interested joining in our Facebook RESPITE Community? *