Parent 1

Last Name:

First Name:

Parent 2

Last Name:

First Name:



City: St: Zip:


Home Phone:



Cell Phone:

Emergency phone:

Any concerns about your child?
Referred By:

Preferred Visit Time:


 * Please note: You will have a longer wait time for an evening visit.
Additional Comments:
  First and Last Name Gender Date of Birth Ethnicity
Child 1:

Child 2:

Child 3:

Child 4:


Teen Parent: Parent(s) under the age of 20 years during the program year.

Child with disabilities or chronic health conditions: Child being served has a physical, cognitive, emotional, or health-related condition or impairment that substantially limits one or more major life activities or qualifies the child for service with Infant Toddler Services.

Parent with disabilities or chronic health conditions: Parent has physical, cognitive, or other health-related condition or impairment that substantially limits one or more major life activities.

Parent with mental illness: Parent has been diagnosed with a thought, mood, or behavior disorder (or some combination for example: anxiety or depression) associated with distress and/or impaired function including maternal or paternal depression.

Low educational attainment: Parent did not complete high school or GED and is not currently enrolled.

Low Income: Families eligible for free and reduced lunches, child care subsidy, WIC, food stamps, TANF, or Head Start/Early Head Start.

Recent immigrant or refugee family: One or both parents are foreign born and entered the country within the past five years.

Substance Abuse: Parent has used or is currently using substances (alcohol, tobacco, or drugs) despite negative social, interpersonal, legal, medical or other consequences. (PATNC recommends this as a risk factor if the substance abuse has occurred at any point during the enrolled child’s lifetime, including prenatal.)

Court-appointed legal guardians and/or foster care: The child has court appointed guardians or is in foster care.

Homeless or unstable housing: Lives in emergency/transitional housing or in a place not intended for regular housing and/or moved more than twice in the past year due to problems with housing.

Incarcerated parent(s): Parent(s) is incarcerated in federal or state prison or local jail or was released from incarceration within the past year.

Very low birth weight: Birth weight is under 1500 grams or 3.3 pounds. This would not need to count as a risk factor if the child is over 2 years and is not experiencing any negative consequences due to being very low birth weight as determined by a reliable and valid screening tool or development assessment.

Death in the immediate family: The death of the child, parent or sibling. (PATNC recommends including this as a risk factor if a death in the immediate family has occurred at any point during the enrolled child's lifetime, including prenatal.)

Domestic Violence: Parent is involved in intimate partner violence.

Child Abuse or Neglect: Suspected or substantiated abuse/neglect of child or sibling(s).

Military Family: Parent/guardian is currently deployed or is within two years of returning from a deployment as an active duty member of armed forces. "Deployment" is defined as any current or past event or activity that relates to duty in the armed forces that involves an operation, location, command, or other duty that is different from the normal duty assignment.

Multiple live births: Pregnancy culminating in two or more live offspring being delivered.

English Learner: English is not the family's first language or the language primarily spoken in the home.

At Risk or Developmental Delay: A delay in the child's development in one or more areas as measured by the ASQ-3 or ASQ: SE. A failed vision or hearing screening completed by a trained professional including a trained Parent Educator.



This information will be sent to the Haysville USD 261 Parents As Teachers Office. Someone from this office will be in contact with you.

If you have questions, call the office at 316-554-2303.