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Grandparents Raising       

Grandchildren
 135 Hoyt Street
 Athens, Georgia 30601
     

Date Completed ________
Client ID ____________

Promoting Safe and Stable Families Reassessment

Section A. Primary Caregiver (PC) Information

▫ Check if PC will participate in any direct services.

Name:

Address:

City:                                                       State:                                                 Zip:

County:

Phone:

Intake Section B. Secondary Caregiver (SC) Information

▫ Check if SC has the same address as the PC.

Name: DOB:_______________________________________          

Relationship to Primary Caregiver:
Address: ▫ Spouse/Partner ▫ Parent ▫ Other Relative
▫ Ex­ ▫ Grandparent ▫ Not Related 
City:                         State:                         Zip: Spouse/Partner

County:

Oldest child receiving services should be listed first, then list all other children by descending age.

DS Shines First Name Last Name Gender DOB Education PC SC


Person ID Status/Grad DD
e
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DS – Check box if child will participate in direct services.               DD – Check box if child has any identified disabilities.

Education Status – Indicate level & current grade PC/SC – Select code that best describes the relationship between 
for each child at intake: each child and the PC and/or SC.

I ­ Infant/Toddler (ages  H ­ High School A­ Adoptive Parent                R­ Other Relative


0­2) O ­ Other Education  B­ Biological Parent              S­ Sibling
P ­ Preschooler (ages 3­ Setting F­   Foster Parent                     T­ Teen Parent
5) N ­ Not in School G­  Grandparent                      X­ Other
E ­ Elementary Grades  H­ Group Home or Res. Facility
K­8
Date: ____________________________

Food Security Questions


These next questions are about the food eaten in your household in the last 30 days and
whether you were able to afford the food you need.

1) During the last 30 days, how often was this statement true:
The food that we bought just didn’t last, and we didn’t have money to get more.
1. Often 2. Sometimes 3. Never
2) During the last 30 days, how often was this statement true:
We couldn’t afford to eat balanced meals.
1. Often 2. Sometimes 3. Never
3) In the past 30 days, did you or other adults in your household ever cut the size of your meals
because there wasn’t enough money for food?

1. Yes, on 3 or more days


2. Yes, on 1 or 2 days
3. No
4) In the past 30 days, did you or other adults in your household ever skip meals because there
wasn’t enough money for food?

1. Yes, on 3 or more days


2. Yes, on 1 or 2 days
3. No
5) In the last 30 days, did you ever eat less than you felt you should because there wasn’t enough
money to buy food?

1. Yes 2. No
6) In the last 30 days, were you ever hungry but didn’t eat because you couldn’t afford enough
food?

1. Yes 2. No
Family Resource Scale

This scale is designed to assess whether or not you and your family have adequate resources (time, 
money, energy, and so on) to meet the needs of the family as a whole as well as the needs of 
individual family members. 

For each item, please circle the response that best describes how well the needs are met on a consistent
basis in your family on a monthly basis.

Date: ____________________________
To what extent are the Does Not at all Seldom Sometimes Usually Almost
not adequate adequate adequate adequat always
following resources adequate
apply e adequate
to your family?
1. Food for two meals a day NA 1 2 3 4 5
2. House or apartment NA 1 2 3 4 5
3. Money to buy necessities NA 1 2 3 4 5
4. Enough clothes for your NA 1 2 3 4 5
family
5. Heat for your house or NA 1 2 3 4 5
apartment
6. Indoor plumbing/water NA 1 2 3 4 5
7. Money to pay monthly NA 1 2 3 4 5
bills
8. Good job for yourself or NA 1 2 3 4 5
spouse/partner
9. Medical care for your NA 1 2 3 4 5
family
10. Public assistance (SSI, NA 1 2 3 4 5
Food Stamps, Medicaid,
etc.)
11. Dependable NA 1 2 3 4 5
transportation (own car
or provided by others)
12. Time to get enough NA 1 2 3 4 5
sleep/rest
13. Furniture for your home NA 1 2 3 4 5
or apartment

To what extent are the Does Not at all Seldom Sometimes Usually Almost
following resources adequate not adequate adequate adequate adequate always
apply adequate
to your family?
14. Time to be by self NA 1 2 3 4 5
15. Time for family to be NA 1 2 3 4 5
together
16. Time to be with NA 1 2 3 4 5
children
17. Time to be with spouse NA 1 2 3 4 5
or close friend
18. Telephone or access to NA 1 2 3 4 5
a phone
19. Babysitting for your NA 1 2 3 4 5
child(ren)
20. Child care/day care for NA 1 2 3 4 5
your child(ren)
21. Money to buy special NA 1 2 3 4 5
equipment/supplies for
child(ren)
22. Dental care for your NA 1 2 3 4 5
family
23. Someone to talk to NA 1 2 3 4 5
24. Time to socialize NA 1 2 3 4 5
25. Time to keep in shape NA 1 2 3 4 5
and looking nice
26. Toys for your child(ren) NA 1 2 3 4 5
27. Money to buy things for NA 1 2 3 4 5
self
28. Money for family NA 1 2 3 4 5
entertainment
29. Money to save NA 1 2 3 4 5
30. Travel/vacation NA 1 2 3 4 5

Intake Section F.  Family Goal Sheet

Grandparents Raising Grandchildren


Family Goal Sheet

Family Name _____________________________________


Plan Date/Year (from/to for month) ___________________

Intern/Case Manager _______________________________

Family Goal Task/Person Progress (Include date Outcome


Responsible if possible)
1.

2.

3.

4.

Comments: _________________________________________________________________

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Notes

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