Family Intake Questionnaire

Demographic Information

The following information is being gathered for FRIENDS WAY in an effort to better illustrate the population we serve. This information will only be used to provide demographic data to our funders and will not be released to any other person, group or agency. All data will be shown in aggregate and no individual data will be shared. Responses are completely voluntary and confidential.

To be completed by primary caregiver:

1. City/Town of Residence ______

2. Date of birth: ___/___/______

3. Gender (circle one): Male Female

4. Race/Ethnicity (check one) ___Hispanic ___Asian ___African American ___Native American ___Caucasian ___more than one race ___Other: (please specify) ______

5. Primary Language spoken at home: ______

6. Secondary Language spoken at home:______

7. Highest educational attainment (check one): ___ Elementary ___ Some College ___ Some High School ___ College Graduate ___ Graduated High School/GED ___ Post-graduate Education

8. Date of Birth and gender of children who will be attending FRIENDS WAY: DOB ___/___/______Male ___Female DOB ___/___/______Male ___Female DOB ___/___/______Male ___Female DOB ___/___/______Male ___Female

6/3/2018 Please turn over… 9. Date of Birth and gender of any children not planning to attend: DOB ___/___/______Male ___Female DOB ___/___/______Male ___Female DOB ___/___/______Male ___Female

10. Employment status (check one): ___Full time ___Part time ___Other ___Not employed

11. Occupation: ______

12. Are there other people living in household? If yes, please specify: ______

13. Annual family income ___Under $20,000 ___$20,000 to $30,000 ___$30,001 to $40,000 ___$40,001 to $50,000 ___Over $50,000

13. Do you have Health Insurance? ___yes ___no

14. Cause of death/loss: ______

15. Relationship of deceased to child/ren: ______

16. What prompted you to contact FRIENDS WAY?______

______

17. How did you hear about FRIENDS WAY? (check all that apply) ___ Media (TV, Radio, print) ___ Friend/Family member ___ Funeral Director ___ Teacher/day care person ___ Doctor, hospital personnel, therapist ___ Guidance Counselor ___ Other (please specify) ______Internet (if so, which site): ______

Thank you.

6/3/2018