Whole Child Profile Questions
Please answer each of the questions below by selecting the appropriate response to the right. Scroll down to view all the questions. If a question does not apply to you, you may leave the response circle blank.

If you hit the backspace key while answering the questions, you will be taken back to the Home page. Click the "Forward" button in your browser's toolbar to return to the Profile. When you are finished answering all of the questions, you will be asked to create a User Name and Password. In order to submit your Profile, you must click the "Submit" button ONLY ONCE. Clicking the button more than once may cause a system error to occur.
   YES   
   NO   
 1 Do you have health insurance/Medicaid for your children under age 6?  
 2 Do you have health insurance/Medicaid or Medicare for yourself and the rest of your family?  
 3 If you are expecting a child, do you have prenatal care? Do not answer if not applicable.  
 4 Do you have a doctor for your children under age 6?  
 5 Are immunizations/shots up to date for all your children under age 6?  
 6 Do you have a doctor for yourself and the rest of your family?  
 7 Do you have a dentist for your children under age 6?  
 8 Do you have a dentist for yourself and the rest of your family?  
 9 Do you have concerns about hearing for any of your children under age 6?  
 10 Do you have concerns about vision for any of your children under age 6?  
 11 Do you have concerns about the physical coordination of your children under age 6?  
 12 Do you have concerns about speech for any of your children under age 6?  
 13 Do you have concerns about the mental health of your children or family?  
 14 Do you have any concerns about the behavior of any of your children under age 6?  
 15 Do you feel your child is developing emotionally, socially and intellectually as well as other children her/his age?  
 16 Do your children under age 6 like to be hugged and comforted?  
 17 Do your children under age 6 get along with other children?  
 18 Do you need services for a child with special needs?  
 19 Would you like information about or need assistance with adoption or foster care?  
 20 Is your family (couple relationship or parent/child relationship) being affected by issues relating to adoption or foster care?  
 21 Would you like information on how to nurture your child?s spirit?  
 22 Do you usually run out of money before your food, shelter and clothing needs are met?  
 23 Do you or your children go to bed hungry?  
 24 Would you like information about providing good nutrition for your children?  
 25 Does your home have running water?  
 26 Do you currently have utilities available in your home such as gas or electricity?  
 27 Do you have access to a phone for emergency purposes?  
 28 Do you have access to reliable transportation when you need it?  
 29 Do you have car seats for your children?  
 30 Do you need to check to see if your car seat is properly installed to protect your child?  
 31 Do you need information about job placement or training?  
 32 Do you need childcare/preschool for any of your children under age 6?  
 33 Do you need after-school care for any of your children?  
 34 Are books for young children available to you?  
 35 Would you like help reading to your child?  
 36 Do you take time to think about yourself and your needs?  
 37 Do you have someone you can depend on when you need help?  
 38 Do you ever worry about the effect of alcohol and drugs on your family?  
 39 Have you moved more than three times in the last year?  
 40 Do you feel safe at home?  
 41 Do you need information about how to make your home safe for your children?  
 42 Is your neighborhood a safe place?  
 43 Do your children have a safe place to play?  
 44 Would you like more information about being a better parent?  
 45 Do you need information about family planning or birth control?  
 46 Do you want information about activities in your community for your family?  
 47 Would you like to volunteer to help families with children under age 6?  
 48 Do you need legal assistance related to taking care of your children under age 6?  
 49 If you have other needs not mentioned above, would you like to be contacted by a Whole Child Advisor to help you with them?  
 

Thank you for completing the Whole Child Profile.

In order to match your family's needs to services and give you a list of providers who can help you, please provide the following confidential information about your family. Your Whole Child Profile will only be shared with your permission.

You only have to fill out the boxes marked "required" to get basic information about providers. However, information such as name, address, and telephone number is essential if you wish to receive specific services.
 
Adults
List each adult living in your household on the rows provided below.
 
First Name
Middle Name
Last Name
Suffix
Sex
Employment Status
(Required)
Relationship To Children
(Required)
Date of Birth
(Required)
Race / Ethnicity
   Person Completing Profile
Adult 1
Adult 2
Adult 3