Find Support - Form - Kent County Parent Support

Referral Information

Do you represent an organization and are you filling out this survey on behalf of a referral?

Family Information

Name:

Email:

Phone:

Preferred Method of Contact:

Phone Call

Important Information

After completing this survey, you will receive your top 3 matched organizations. An email will be automatically sent to you and you will have the option to automatically send your information to the programs/organizations you matched with. If you choose to share your information they will contact you directly to complete the program intake process.

Your youngest child's date of birth (or expected due date if pregnant): i

What type of health benefits does your child have (or the mother if pregnant)? i

Private Insurance
Medicaid
Combination
Uninsured

Is this your first child? i

Yes
No

Are you currently receiving or think you might be eligible for WIC? i

Yes
No

Over the past two weeks, how often have you had little interest or pleasure in doing things? i

Not at all
A few days
More than half the days
Nearly every day

Over the past two weeks, how often have you felt down, depressed, or hopeless? i

Not at all
A few days
More than half the days
Nearly every day

Have you ever been treated for or told you have a mental health concern (such as depression, bipolar disorder, anxiety, schizophrenia, etc.)? i

Yes
No

Do you have someone dependable to help you with your child (or to support you if pregnant)? i

Yes
No

Do you have transportation to your child’s medical appointments? i

Yes
No

Do you enjoy holding your child? i

Yes
No

Is your child easy to console most days? i

Yes
No

Do you feel safe with the people in your home? i

Yes
No

Are you currently experiencing homelessness? i

Yes
No

Are you interested in learning how your baby or child is developing and growing? i

Yes
No

Has Child Protective Services (CPS) contacted you recently for any reason? i

Yes
No

Has your childcare provider expressed concerns about your child's behavior? i

Yes
No

Do you have concerns or questions as you care for your baby or child? i

Yes
No

Do you have significant concerns about your child's current development (e.g., not crawling, talking, or walking when expected)? i

Yes
No

What is your zip code? i