Understanding Your Family's Needs Part 1: Child and family demographics We'll start by getting to know you and your family. The information you provide here becomes the foundation of your electronic health record at Morneau Shepell. Question Title * 1. Who would you like us to help? Child's name: Date of birth: Address: City: Postal code: Question Title * 2. What is their gender? Female Male No answer Other Question Title * 3. Child lives with: Both parents Mother Father Grandparent(s) Guardian Independent Group Home Other (please specify) Question Title * 4. Your contact information: Name: * Relationship to child: * Home phone: Cell phone: E-mail: * Occupation: Work phone: Question Title * 5. Your partner's contact information: Name: Cell phone: E-mail: Occupation: Work phone: Question Title * 6. Do you have any other children living in your home? Yes No If yes, please provide more information: Question Title * 7. Are there any unique things about your family dynamic that you'd like us to know? (e.g. Child stays with Grandma three times per week.) Yes No If yes, please specify: Next
