SAFE: Is a voluntary, free, evidence-based home visiting program serving children ages 0-5 years. SAFE is a 6 session per module program with home visits at least once a week. Comprised of three modules including: health, safety, parent/infant interaction, and parent/child interaction.

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1. Today's Date

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2. Primary/Caregiver Information

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3. Caregiver's Date of Birth

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4. Caregiver's Gender

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5. Primary language spoken at home

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6. Are you currently pregnant?

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7. Estimated Due Date (if prenatal)

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8. Educational Attainment (Highest Level Completed)

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9. Primary Medical Insurance Provider

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10. Please provide information for the child(ren), age five or under, who will primarily receive services from SAFE Program.

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11. Children's Date of Birth

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12. Child(ren) Health Insurance

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13. Caregiver/Parent Contact Information

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14. How did you hear about SAFE program?

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15. Are there any additional comments you would like to add?

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