Families Need Assessment

1. Name (Optional)

2. Date of Birth

3. Postcode

4. Are you currently a service user with the Abbey Centre?

5. If no, would you like to be a member?

6. How would you describe your ethnicity?

7. What is the main language used in your household?

8. How would you describe yourself?

9. How many adults (age 18 plus) currently live in your household?

10. How many adults are currently caring for children under 18 in your household?

11. How many children currently live in your household that are aged 0-4?

12. How many children currently live in your household that are aged 5-11?

13. How many children currently live in your household that are aged 12-17?

14. Do any of your children have special needs or a disability?

15. Which of the following most closely describes you? (please tick all that apply)

16. Do you receive any of following welfare benefits? (please tick all that apply)

17. Are you finding it difficult to cover basic household costs?

18. Please describe your household status (Please tick that apply)

Renting from housing association or council
Private renter
Temporary accommodation
Shared ownership
Own my home
Sheltered accommodation
Other - Please Specify (Required) Please enter an 'other' value for this selection. * This question is required.

Section A - About You and your Family