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This confidential form is intended to be completed in an interview with parent(s)/guardian(s) enrolling a child into the program. It is not to be given to the parent(s)/guardian(s) to complete. The completed Prevention Initiative Parent Interview Form will be used to complete the Preschool for All Eligibility Form. The program Parent Interview Form must correspond with Eligibility Form the program uses. The staff respond to the questions in writing as revealed by the parent/guardian. Some areas have lightly shaded wording to indicate the types of responses that belong in that space.  \n\n| Person Interviewed: | Date: |  | Relationship to child: |  |\n| --- | --- | --- | --- | --- |\n| Child’s full name (First, Middle, Last): |  |  | Date of birth: |  |\n| The name I would like my child to be called is: |  |  |  |  |\n| How did you hear about this program? |  |  |  |  |\n| 1. Parent’s name: |  | 2. Parent’s name: |  |  |\n| Date of birth: |  | Date of birth: |  |  |\n| Address: |  | Address: |  |  |\n| City: State: ZIP: |  | City: State: ZIP: |  |  |\n| Phone: |  | Phone: |  |  |\n| Email: |  | Email: |  |  |\n| Marital status: |  | Marital status: |  |  |\n| Language spoken in home: |  | Language spoken in home: |  |  |\n| Translator-Yes/No (If yes, describe): |  | Translator-Yes/No (If yes, describe): |  |  |\n| Highest grade completed in school: |  | Highest grade completed in school: |  |  |\n| Place of employment:\u003Cbr>Address:\u003Cbr>Phone number: |  | Place of employment:\u003Cbr>Address:\u003Cbr>Phone number: |  |  |\n| Child lives with:\u003Cbr>o Parent(s)?\u003Cbr>o Foster parent(s) or legal guardian(s)?\u003Cbr>o Other (specify):\u003Cbr>Names (if other than parents): |  | List siblings: |  | Date of birth |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| Notes: |  | Are any of the child’s siblings having academic\u003Cbr>difficulty or trouble in school? If yes, please explain: |  |  |\n\n\n| Child’s Medical History |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Was there anything unusual about the pregnancy or delivery of this child or did he/she experience any serious health problems at birth? Yes/No\u003Cbr>If yes, please explain: |  |  |  |  |  |  |  |\n| Was there any drug or alcohol use during this pregnancy? Yes/No If yes, please describe: |  |  |  |  |  |  |  |\n| Length of this pregnancy: |  |  |  |  |  |  |  |\n| Weight of child at birth: | Current weight: |  |  |  |  | Current height: |  |\n| Did this child experience feeding difficulties as an infant? Yes/No If yes, please explain: |  |  |  |  |  |  |  |\n| Was this child on a respirator? Yes/No |  |  |  | If so, how long? |  |  |  |\n| Is your child experiencing health issues? (Please indicate if the illness is chronic or terminal. ) If yes, please explain: |  |  |  |  |  |  |  |\n| Does your child have a diagnosed disability?\u003Cbr>If yes, please explain: |  |  |  |  |  |  |  |\n| This child needs a referral to Child and Family Connections. Yes/No |  |  |  |  |  |  |  |\n| Is this child taking any medication(s)? Yes/No\u003Cbr>What medication(s) is this child taking? |  |  |  |  |  |  |  |\n| Why is this child taking medication? Condition(s): |  |  |  |  |  |  |  |\n| Please list any surgeries this child has had. |  |  | Date |  | Hospital |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n| • Please list the name(s) and contact information of the doctor(s) for this child. |  |  |  |  |  |  |  |\n| Doctor |  | Clinic/Office |  |  |  |  | Phone number |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n\n\n| Do you notice, or has a doctor reported, any of the following in your child? (Circle) |  |  |  |  |  |  |  |","cbCaig21FDJifWns","https://ap.wps.com/l/cbCaig21FDJifWns","pdf",241834,7,"English","# Prevention Initiative Parent Interview Form\n## Program use and confidentiality\n## Interviewer-written parent/guardian responses\n## Section: Person interviewed and contact details\n## Section: Child medical history\n## Section: Health concerns and screening\n## Section: Therapy services and provider information","[{\"question\":\"Who should complete the Prevention Initiative Parent Interview Form?\",\"answer\":\"The form is intended to be completed in an interview with the parent(s) or guardian(s) enrolling a child. It should not be given to the parent(s) or guardian(s) to complete themselves.\"},{\"question\":\"How is the completed form used after the interview?\",\"answer\":\"The completed Prevention Initiative Parent Interview Form is used to complete the Preschool for All Eligibility Form.\"},{\"question\":\"What information is collected about the child’s medical and developmental needs?\",\"answer\":\"The form collects medical history including pregnancy and birth issues, illnesses and health conditions, disability or diagnosed concerns, medications, adaptive equipment, and therapy services received, along with relevant provider contact information.\"}]","Prevention Initiative Parent Interview Form - SAMPLE | PDF",1789308544]