To be completed by the end of Week 3. Please complete a
separate form for each child that you are hosting. |
Family Name: |
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City, State |
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Your E-mail: |
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Summer Miracle Child First
Name: |
|
Summer Miracle Child Last
Name: |
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About the
Child: |
1. What have you
noticed that has changed about the child since you wrote your previous
evaluation? |
|
|
2. Child's current
emotional state (please describe briefly and chose one answer below that
best reflects your host child's emotional state). |
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Emotional State (Please
Select One):
Unhappy
Rarely Happy
Mostly Happy
Very Happy |
|
3. Child's interaction
with family members (please describe briefly and chose one answer below
that best reflects your host child's interaction with family
members). |
|
Interaction With Family
Members (Please Select One):
Does Not
Interact
Has Hard Time Interacting
Interacts Pretty
Well
Interacts Very Well |
|
4. Child's interaction
with others (please describe briefly and chose one answer below that best
reflects child's interaction with other adults and peers). |
|
Interaction With Others
(Please Select One):
Does Not Interact or Indiscriminately
Interacts
Has Hard Time Interacting
Interacts Pretty
Well
Interacts Very Well |
|
5. Any concerns/problem
behaviors and how were they addressed? (Please describe briefly if any).
In addition, mark all that apply below; if problem not listed mark
'other.' |
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Eating problems
Hyperactive
Aggressive to others/animals
disruptive of property
stealing
smoking |
sleeping problems/nightmares
Tantrums/angry outbursts
Bedwetting/soils in pants
lying
playing with fire
other |
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6. Any
health problems and how were they addressed? |
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7. What activities does the child
enjoy most? |
|
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8. What needs do you
have that have not been met? |
|
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9. What needs does the
child have that have not been met? |
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10. Are there any concerns about
this child you would like to discuss with Kidsave or a Social Worker? |
Kidsave Representative should call
Social Worker should call |
Best Time of Day to Reach You? |
|
Thank you for
your help. We appreciate the challenges in completing these questionnaires
on a weekly basis. Your time is much appreciated. |
| A copy of this completed questionnaire will be sent
to Kidsave. You will also receive a confirmation copy by
return E-mail for your records. |
|
|
(Click submit to send.) |
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