PAT INFORMATION AND ENROLLMENT FORM

 

CONTACT INFORMATION
Parent 1

Last Name:

First Name:

  Gender Date of Birth
 
   
 

Address:

City: St: Zip:

 

Phone:

email:

  Ethnicity Race Speaks English Primary Language
 

  Marital Status Relationship to Child Currently Enrolled in Highest Level of Education Completed
 
  Current Employment Current Housing Health Insurance
 
   
 
Parent 2

Last Name:

First Name:

  Gender Date of Birth
 
   
 

Address:

City: St: Zip:

 

Phone:

email:

  Ethnicity Race Speaks English Primary Language
 

  Marital Status Relationship to Child Currently Enrolled in Highest Level of Education Completed
 
  Current Employment Current Housing Health Insurance
 
 
Any concerns about your child?
PAT PROGRAM INFORMATION
Referred By:

Preferred Visit Time:

 

 * Please note: You will have a longer wait time for an evening visit.
 
Additional Comments:
CHILDREN AGE 0-5
  First and Last Name Gender Date of Birth/Due Date if Prenatal Ethnicity
Child 1:


       
  Speaks English Primary Language Health Insurance Living in the Home
 

 
  First and Last Name Gender Date of Birth/Due Date if Prenatal Ethnicity
Child 2:


       
  Speaks English Primary Language Health Insurance Living in the Home
 

 
  First and Last Name Gender Date of Birth/Due Date if Prenatal Ethnicity
Child 3:


       
  Speaks English Primary Language Health Insurance Living in the Home
 

 
  First and Last Name Gender Date of Birth/Due Date if Prenatal Ethnicity
Child 4:


       
  Speaks English Primary Language Health Insurance Living in the Home
 

 
  First and Last Name Gender Date of Birth/Due Date if Prenatal Ethnicity
Child 5:


       
  Speaks English Primary Language Health Insurance Living in the Home
 

Other People Living in the Home
  First and Last Name Gender Date of Birth/Due Date if Prenatal Relationship to enrolled child(ren)
Other 1:

 
  First and Last Name Gender Date of Birth/Due Date if Prenatal Relationship to enrolled child(ren)
Other 2:

 
  First and Last Name Gender Date of Birth/Due Date if Prenatal Relationship to enrolled child(ren)
Other 3:

 
  First and Last Name Gender Date of Birth/Due Date if Prenatal Relationship to enrolled child(ren)
Other 4:

Family Income
  Average Monthly Income Number in Household Dependent on this Income
 
Sources of Income (check all that apply)

Child support/alimony


Energy Assistance

SNAP


Housing Assistance

Salary/Wages


SS/Disability

TANF


Unemployment

WIC


Other
FAMILY EXPERIENCES: Strengths and stressors (check all that apply)

Parents who are pregnant or parenting under the age of 21.


Child has a significant delay, disability, or condition that impact development and/or effects overall family well-being.

A parent has a physical or cognitive impairment (disability or chronic health condition) that substantially limits their ability to parent.

Child has serious behavior concerns.

Parent did not complete high school or pass an equivalency exam and is not currently enrolled.

Family is eligible for free and reduced lunches, public housing, child care subsidy, WIC, food stamps/SNAP, TANF, Head Start/Early Head Start, and/or Medicaid.

One or both parents is foreign-born and entered the country within the past five years. This does not include those from Puerto Rico, Guam, and the US Virgin Islands.

Parent has repeatedly used or is currently using substances despite negative social, interpersonal, legal, medical, or other consequences during child’s lifetime.

Child or young parent is in foster care and has court-appointed legal guardians or is living in some other temporary caregiver situation.

Family lacks fixed, regular, and adequate nighttime residences, including those who share others’ homes due to loss of housing or economic hardship; lives in motels, hotels, or camping grounds due to lack of adequate alternative accommodations; resides in emergency or transitional shelters; or resides in public or private places not designed for or used for regular sleeping accommodations.

Parent(s) is or was incarcerated in federal or state prison or local jail, halfway house or is part of a boot camp or weekend program requiring overnight stays during child’s lifetime.

The child’s birth weight is under 3.5 pounds and the child was born at less than 37 weeks’ gestational age.

The death of a child, parent/guardian, or sibling during child’s lifetime.

Parent/guardian is a survivor of intimate partner violence.

Reported or substantiated abuse/neglect of child or sibling, including but not limited to a current or recent open case with the child welfare system for any reason.

Parent/guardian is planning for deployment, currently deployed, or within two years of returning from a deployment as an active duty member of the armed forces.

Parent/guardian has formerly served in the US Armed Forces.

Family speaks limited English.

School age children with low academic achievement.

Child is being parented by one parent in the home.

Three or more children under the age of 6.

Adoptive parent.

First time parents.

 

 

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.