Single-Parent Household Needs Assessment Form
Parent/Guardian Name
Contact Information (Phone or Email)
Home Address
Number of Children
Age(s) of Child(ren)
Employment Status
Employed Full-time
Employed Part-time
Unemployed
Student
Other
Primary Needs (Select all that apply)
Housing
Food Assistance
Childcare
Transportation
Education/Training
Employment Assistance
Healthcare
Other
Do you have access to family/friend support?
Yes
No
Limited
Main Challenges You Are Facing
Goals for You and Your Children
Services or Support You Would Find Most Helpful
Additional Comments