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Departments
477 Program
Child Family Services
Education
Emergency Management
Enrollment
Facilities
Finance
First Light Shellfish Farm
Food Pantry
Health and Human Services
Historic Preservation & NAGPRA
Homeland Security
Housing
Human Resources
Indian Health Services (IHS)
Language
Museum
Natural Resources
Nutrition
Old Indian Meeting House
Public Works
TERO
Tribal Administrator
Workforce Investment Opportunities (WIOA)
Weetumuw School
Judicial
Judicial Branch Home
About the Court
MWT Courts
Meet the Judges
Elders Judiciary Committee
Guides, Forms, and Fees
Bar Association & Membership
Court Bulletins
Decided Cases & Supreme Court Opinion
Law and Policies
Pending Cases
Sovereign Immunity
Tribal Court Library
Employment & Internships
Probation
Prosecutor Office
Public Defender
Security
Homeland Security
Police Department
Security Department
Victim Service Program
Powwow
Powwow
Powwow Princess
Culture
Culture
Timeline
Tribal Chief
Past Leaders
Councils
Tribal Council
Notices and Postings
Meetings
News
Mittark
Mittark Archives
Tribal News
Events
Press Releases
CDC
Opioids
Opioid Education
The 360 Project
Community Wellness Survey
Opioids Fact Sheet
Opioids Brochure
Opioids Wallet Card
Treatment News
Jobs
Donations
Kinship Support Needs Assessment
Provider Name
*
Name of Person Completing the Form
*
First Name
Last Name
Contact Phone Number
*
(###)
###
####
Number of Children in Your Care
*
Ages of Children
*
Relationship to Children
*
Date of Placement
*
MM
DD
YYYY
Initial Needs
Please rate the support needs with 1 being no need required and 5 being urgent need required. 1 = No 2 = Low 3 = Moderate 4 = High 5 = Urgent
Clothing
*
1
2
3
4
5
Baby Items (car seat)
*
1
2
3
4
5
Bedding
*
1
2
3
4
5
Food
*
1
2
3
4
5
Rent/Utility Assistance/Housing
*
1
2
3
4
5
Child Care
*
1
2
3
4
5
Emergency Financial Support Medical/Assistance for Child/Self
*
1
2
3
4
5
Transportation
*
1
2
3
4
5
Hygiene Products
*
1
2
3
4
5
Additional Comments on Needs
Ongoing Needs: Training/Support
Please rate the support needs with 1 being no need required and 5 being urgent need required. 1 = No 2 = Low 3 = Moderate 4 = High 5 = Urgent
Financial (TANF/Child Support/SSI/Snap/Food Stamps/Nutrition/WIC)
*
1
2
3
4
5
Advocating for Child/Self
*
1
2
3
4
5
Budgeting (credit counseling) Parenting/Discipline/Rules/Boundaries
*
1
2
3
4
5
Child Development
*
1
2
3
4
5
Nutrition
*
1
2
3
4
5
Home Safety/Childproofing Child Exposure (Domestic Violence/Substance Abuse/Sexual Abuse/Trauma)
*
1
2
3
4
5
Family Communication (Bio Parents/Extended Family)
*
1
2
3
4
5
Role Definition
*
1
2
3
4
5
Education (School Enrollment/Tutoring/Mentoring/IEP/College)
*
1
2
3
4
5
Additional Comments
Ongoing Needs: Mental Health Services
Please rate the support needs with 1 being no need required and 5 being urgent need required. 1 = No 2 = Low 3 = Moderate 4 = High 5 = Urgent
ADHD/ADD
*
1
2
3
4
5
Children and Trauma
*
1
2
3
4
5
Stress Relief
*
1
2
3
4
5
Grief and Loss
*
1
2
3
4
5
Anger Management
*
1
2
3
4
5
Conflict Resolution
*
1
2
3
4
5
Family Counseling
*
1
2
3
4
5
Individual Counseling
*
1
2
3
4
5
Respite
*
1
2
3
4
5
Activities (Child/Self/Summer Programs)
*
1
2
3
4
5
Support Group (Child/Self)
*
1
2
3
4
5
Employment Resources
*
1
2
3
4
5
Legal Issues
*
1
2
3
4
5
Additional Comments
Identified Social Supports - Who can you count on? How can they help?
Immediate/Extended Family Member
Neighbors/Friends
Church
Community Based Organizations
Other
Moving Forward
What is the greatest strength you bring as a kinship caregiver?
*
What is your greatest worry in being a kinship caregiver?
Support plan to address needs and next steps
*
Thank you!
