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Questionnaires
Caregiver Questionnaire – Probation
"
*
" indicates required fields
User Information
This survey is for anyone who is providing the 24/7 care of the child/youth, regardless of the placement type.
What is reported in this questionnaire may be included in the local board’s report to the legal parties to the case.
Your Name
*
First
Last
Email
Youth Information
If responding for more than one youth, use the oldest youth’s first name and last initial.
Name of Youth
*
First
Last (1st initial only)
Address
*
City
State / Province / Region
Board #: If Known
Meeting Date: If Known
System Contact
Do you receive adequate communication and updates from the Probation Officer regarding the needs of this youth?
Have you received enough background information regarding the youth to meet his/her needs? (medical/educational/behavioral/mental health, or any other special needs)
What support have you asked for to assist you in caring for this youth?
Medical Information
List the youth’s current prescription medications:
Provide dates of the following exams for the youth: Physical, Dental, and Vision Exam
What are the youth’s current mental health needs?
What are the youth’s unmet medical and/or mental health needs?
What positive behaviors has the youth been engaging in/demonstrating?
What negative behaviors has the youth been engaging in/demonstrating, if any?
To your knowledge, has the youth ever been a victim of sex or labor trafficking?
Services
What services/treatments are being provided to the youth?
Describe the progress the youth is making with the provided services/treatments.
What unmet needs does the youth have?
Is the youth diagnosed with a developmental disability?
Yes
No
Has the youth qualified for DD specific services? If yes, describe services that are being provided.
What unmet DD specific needs does the youth have, if any?
If the youth is 18, is there a plan for DD serivces and suppports after the youth turns 19?
Education
Describe how the youth is doing in school. (grades, behaviors, successes)
Describe what extracurricular activities the youth enjoys and is involved in.
Is there anything keeping the youth from being involved in the above mentioned activities?
Does the youth have a current IEP/504 plan? If applicable, what is the IEP/504 plan for?
Are there educational concerns that are not being addressed?
Are there any education supports the youth needs that are not being provided? Explain.
Additional Information
What else can you tell us that we haven’t already asked about?
Although not required, if you would like to submit any additional related documents you may do so below:
Accepted file types: pdf, xls, xlsx, doc, docx, jpg, png, gif, tiff, txt, Max. file size: 64 MB.
By returning this document, you confirm that the information is true and accurate and that you understand this information may be shared with the legal parties to the case.
