Family Assessment Form Family Assessment Child's Name * Full Name Child's Date of Birth * MM-DD-YYYY format Family Assessment Details This Family Assessment is designed to determine the resources, priorities and concerns of a family as it relates to the enhancement of the child’s development. The Family assessment is voluntary and must be offered as a component of an Initial Early Intervention (EI) Evaluation. Should you choose not to participate in the process, it shall in no way impact on the determination of your child’s eligibility to receive EI services. If you wish to complete the Family Assessment, please provide the information as indicated below. If it is your choice to decline this opportunity, please fill out the other form named, "Family Assessment (Decline)". Please read. Please state your concern(s) about your child: * Have other family members had the same or similar difficulties? * How would you rate your child’s difficulty in terms of severity? * Mild Moderate Severe Are you able to transport your child to appointments? * I would be interested in information or help in the following areas (Check all that apply): * Housing, clothing, jobs, food, telephone My child's disability or area of need(s), what it means Other kinds of help that might be available Integrating our child into community activities Other (please describe if applicable) Parent Signature (typed text digital signature) * Date * MM-DD-YYYY format Submit If you are human, leave this field blank.