Family Outcome Tool
We are required to complete a needs assessment with all enrolled families for program reporting. This tool will be used to recognize strengths and help staff connect families to resources. Not all criteria within the letters will apply. Feel free to circle what does apply and cross out what does not apply.
Child’s Name: ______
Parent/Guardian’s Name: ______Program Year: ______
General
1. Housing – Where have you lived in the last year? Tell me about your current housing, what do you like about it and what changes (repairs, size, safety) would you like to see? How do you pay your housing bills and utilities (employment, local agencies, family/friends)? Are you aware of local resources that can assist with housing and utility bills and do you feel comfortable reaching out to them? / Date: / Date:
E. Able to own or live in long term affordable housing. Safe housing. Enough room for family size. Suits needs and preferences. Able to pay utilities.
D. Safe and Secure Dwelling for at least 12 months. Able to pay rent/mortgage. Able to pay utilities. Repairs taken care of.
C. Semi-permanent. Relatively safe & secure. Some repairs needed. Mostly have ability to pay housing/utilities/repairs. Minor landlord issues. Some help from agencies to get.
B. Temporary housing. Live with friends/family. Money for rent/utilities uncertain. Unsafe or crowded. No money for repairs. Landlord not fixing problems. Use help from agencies to get by. Utilities shut off or on the verge.
A. Homeless or on verge. Very temporary housing (such as with friend for 1 week). At a shelter, camping, live in vehicle, etc. No income for housing. Dangerous or bad situation. Utilities shut off.
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2. Food/Clothing – How do meals look at your house? What does your family enjoy eating? What kind of resources and/or knowledge helps you prepare meals for your family? How do you clothe everyone in the family? What local resources have you used to meet your family’s nutritional and clothing needs in the past? / Date: / Date:
E. Food always available. Regular and balanced food. Variety and high quality foods. Clean and durable clothes.
D. Always have resources for healthy food/needed clothing. Dietary requirements for special conditions i.e. pregnancy,
Diabetes, etc.
C. Sufficient personal and community resources for food and clothing.
B. Limited knowledge of food, food preparation and clothing resources. Not enough food daily.
A. No food and preparation. Clothing inadequate. Malnutrition. Eating concerns and/or disorders.
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3. Employment – Where are you (or your partner) working at this time? Tell me about your job, what do you like, what do you dislike? How long have you worked there? Is your family’s employment adequate enough to meet your needs? If you are not working, what obstacles are in your way? / Date: / Date:
E. Permanent and stable. Full benefits. Above average employment. Upgrading skills. Transferable skills.
D. Full-Time or adequate job. Meets basic needs. OK benefits.
C. Stable adequate or almost adequate job. Doing ok, but could do better, with the right training or job.
B. Temporary or part-time. Under-employment. No benefits. Limited skills. Inadequate pay/benefits.
A. Unemployed. Disabled with no benefits. No/little prospects or skills. Long term unemployment.
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4. Education – What was school like for you? Are you interested in completing high school or completing your GED? If so, what obstacles do you need to overcome to succeed (special education needs, local programming, internet capability, transportation)? What are your educational goals (college, job training)? What resources could support your goals? / Date: / Date:
E. Attending College. Chosen profession. Obtaining degree. Proficient with computer and Internet.
D. Have GED or HS Diploma. Able to access needed resources to attend college. No need for remedial courses.
Knowledgeable with computer/Internet.
C. Have GED or HS Diploma. Able to access needed resources to attend college or job training. Need a few remedial
courses. Able to use computer/internet.
B No GED or HS Diploma. Able to access GED training. Able to access job training. Remedial courses needed. Needs
some skills to use computer/internet.
A. No GED or HS Diploma. Need English as second language. Need remedial courses in various areas, e.g. math, reading, writing, etc. No skills with computer/internet.
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5. Transportation – How do you get to work, appointments, or to dr. appointments? What are your transportation needs? If you do not have your own transportation, who helps you get where you need to go? Do you have access to public transportation? / Date: / Date:
E. Reliable vehicle. Have driver's license. Have money for car repairs, payments, gas, regular maintenance and insurance.
D. Reliable vehicle. Have money for car repairs, payments, gas and insurance. Have driver's license.
C. Semi reliable vehicle. Able to pay for some repairs, but may be not right away. Able to get reliable rides. Have driver's
license. Have insurance. Can afford needed gas.
B. Unreliable vehicle. May not be able to pay for needed repairs/gas. No driver's license. No insurance. Unreliable resources for transportation.
A. No vehicle. No access to transportation via other people. Take public transportation, walk or ride bikes. No driver's license.
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6. Financial – How do you feel about your family’s income? Do you feel you have enough income to meet your family’s needs most of the time? Do you feel comfortable accessing resources when you need to? Do you receive any assistance through DHS or other agencies? / Date: / Date:
E. Reliable Income. Able to pay all bills on time. Have saving/retirement accounts. Have credit cards/good credit. Able to follow budget.
D. Adequate Income. Able to pay most bills on time. Mostly able to follow budget. OK credit.
C. Stable Income. Struggle to pay bills on time. Access resources as needed. Fear unexpected costs. Some budgeting
skills.
B. Inadequate income. Unable to pay all bills. Use assistance to get by. Need help with budgeting skills.
A. Little to no income. Depend strongly on assistance to survive. No budgeting skills. Facing eviction/repossession. Go
without meals/medical.
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7. Health - Tell me about your family’s/child’s health. Who is your child(ren)’s pediatrician? Who is your Dr.? Who is insured in the family? / Date: / Date:
E. Family doctor. Family dentist. Immunizations up to date. Iron level test done. Lead level test done. Everyone is
healthy. Money/insurance for medical. Yearly physicals.
D. Family doctor and dentist. Immunizations up to date. Everyone is healthy. Money/insurance for medical.
C. Access to doctor and dentist through clinics. Mostly able to see doctor/dentist when needed. Mostly enough insurance.
Have most immunizations. Mostly able to get medications.
B No/poor Insurance. No regular doctor or dental. Use Emergency Room for Doctor. Need help finding resources. Only go to doctor/dentist when an emergency. Unmet medical/dental needs. Behind on immunizations.
A. No regular doctor or dental. Need help finding resources. No Insurance. Can't afford doctor/dentist. Can't afford/skipping needed medications. Serious illness in family.
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8. Family/Relationships – (Circle of Support could be a useful tool) – Who is important to your child and yourself? What do these relationships look like (nurturing, playful and stable? Stressed? What do you enjoy in your community? Tell me about your relationship with your child(ren). What goes well and what is more difficult? What parenting techniques work well for your child (praise, redirection, choices, routine, etc.)? / Date: / Date:
E. Stable/nurturing relationships. Positive techniques of guidance. Strongly involved in community. Strong support network. Supportive environment.
D. Relationships good. Environment good. Involved in Community. Mostly positive parenting techniques. Stable support
network.
C. Somewhat stressed. Stable relationships. Stable environment. Mostly good parenting skills. Able to access resources.
Parenting and or relationship skills could be improved. Some community involvement. Some support available.
B. Behavioral Issues. Overwhelmed. Little or no support. Discipline that is not working - inconsistent, not knowing how to respond or what to do, harsh or negative reactions. Need help with resources, parenting skills. Relationship issues.
A. Domestic violence. Substance abuse. Mental/verbal abuse. Severe behavior issues. Relationship breakdowns.
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9. Mental Health – As parents, we all have stress. How do you deal with stress, depression or anxiety? If a parent talks about strong depression, anxiety or any other mental health issue, follow up with: Is your doctor aware of your anxiety, depression, etc.? Are you receiving counseling? Has your Dr. prescribed any medications? If so, are they working for you and do you take them consistently? Who supports you when you are having a difficult day? / Date: / Date:
E. Self-Confident. Strong sense of identity. Non-stressed. Strong relationships. No mental health problems.
D. No mental health problems, but low confidence/sense of identity. Good relationships. Mild stress at times.
C. Some mental health issues, but medication/coping skills take care of it. In counseling/treatment. Have support. Able to
function normally.
B. Able to function most days. More good days than bad. Medications partially helping. No treatment until in crisis. Not
enough support.
A. Unmanaged depression. Anxiety. Eating disorder. Other mental health issue. Struggles to cope. Substance abuse. Unable to function in society. More bad days than good. Have had thoughts of harming self or others.
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Distribution: Original: family file; Teachers completing FOT, emails reporting summary to support staff; EHS enters FOT in Child Plus; FES enters FOT in Child Plus
6/30/17 P:\HeadStart\Univ\SS\Family Outcome Tool