Whole Child Profile Questions
Please answer the questions below by selecting the appropriate response to the right. Scroll down to view all the questions. If a question does not apply to you, you may leave the response circle blank.

If you hit the backspace key while answering the questions, you will be taken back to the Home page. Click the "Forward" button in your browser's toolbar to return to the Profile. When you are finished answering all of the questions, you will be asked to create a User Name and Password. In order to submit your Profile, you must click the "Submit" button ONLY ONCE. Clicking the button more than once may cause a system error to occur.
   YES   
   NO   
1 Do you and your children have health insurance?  
2 Do you and your children need a doctor?  
3 Do you and your children need a dentist?  
4 Are immunizations and/or regular doctor exams up-to-date for you and your children?  
5 Do you have concerns about the following for any of your children:  
 
 
    •    Hearing  
    •    Vision  
    •    Speech  
    •    Physical Coordination  
    •    Specific Health Condition  
6 Do you have concerns about your child's weight?  
7 Are you pregnant?  
8 Do you need prenatal care?  
9 Do you want to prevent future pregnancy and need information about birth control?  
10 Would you like information about safe sex practices?  
11 Do you have difficulty getting medicines for your family or yourself?  
12 Do you need help to overcome extreme stress due to:  
 
 
    •    Depression  
    •    Divorce/Separation  
    •    Terminal Illness  
    •    Death/Loss  
    •    Drugs, Tobacco or Alcohol Use  
13 Do you smoke?  
    •    Are you interested in quitting in the next 30 days  
14 Does anyone else in the household smoke?  
    •    Are you interested in receiving information on Secondhand Smoke?  
15 Do you have any concerns about the behavior of any of your children?  
16 Does your child (ages 2-5) get along with others in or out of school?  
17 Do you suspect that your child has ever used alcohol, tobacco or drugs?  
18 Does your child display extreme mood swings?(crying, kicking, withdrawn)  
19 Is your child preoccupied with suicide or death?  
20 Do you have a working smoke detector in the home?  
21 Do you have transportation for the following:  
 
 
    •    Work  
    •    Childcare  
    •    Doctor Visits  
    •    Grocery Shopping  
    •    Social Services  
22 Is there violence in your home/neighborhood?  
23 Do you need legal assistance? (divorce, custody, child support, immigrations)  
24 Would you like information on swimming classes?  
25 Do you need car seats for your children?  
26 Do you need a place to live?  
27 Do you sometimes need help paying for food, housing, utilities, or clothing?  
28 Do you need information about:  
 
 
    •    Job Placement  
    •    GED Preparation  
    •    Alternative Education  
    •    English as a Second Language Training  
    •    College Courses  
    •    Improve Reading Skills  
29 Do you need to learn how to stretch your dollar? (Budgeting, thrift shops, food savings)  
30 Do you want information on resources for children/adults with special needs?  
31 Are you seeking child care and/or schools for any of your children?  
32 Are you interested in youth programs for any of your children?  
33 Do you feel your child is learning and developing as well as other children their age?  
34 Do you feel your child is doing well in school?  
35 Would you like more information on parenting?  
36 Would you like information about becoming a foster parent or adopting a child?  
37 Are you reading/sharing stories with your child several times a week?  
38 Are any of your children having attendance issues in school?  
39 Do you want information about recreational programs for you and your children?  
40 Are you interested in becoming a volunteer in your community?  
41 Are any of your children unsupervised after school?  
42 Has your child had sexual experiences?  
43 Are you concerned about who your child's friends are?  
44 Do you want information on faith-based programs for you and your children?  
45 Do you want information on how to teach your children to keep their promises?  
46 Do you want information on how to teach your children not to be judgmental?  
47 Do you want information on how to teach your children not to blame others for their mistakes?  
48 Do you want information on how to set a good example for what you say and do?  
49 Do you want information on how to teach your children to treat others the way they want to be treated?  
50 Do you want information on how to teach your children to obey the rules?  
 A-24 Do you have a gynecologist?  
 A-25 In the last year have you had a doctor's visit?  
 A-26 In the last year have you had a Regular Check-Up?  
 A-27 In the last year have you had a Pap Smear?  
 A-28 In the last year have you had a Breast Exam?  
 A-29 In the last year have you had a Cholesterol Test?  
 A-30 In the last year have you had a Blood Pressure Check?  
 A-31 STDS (sexually transmitted diseases) cause extreme complications when pregnant. Are you concerned that you might have an STD?  
 A-32 Do you have diabetes, high blood pressure, or asthma?  
 A-33 Are you trying to get pregnant?  
 A-34 Have you waited two years before trying again?  
 A-35 Do you smoke?  
 A-36 Alcohol, Tobacco & Drugs cause extreme complications when pregnant. Do you need help to overcome drug & alcohol abuse?  
 A-37 Are you feeling burnt out?  
 A-38 Are you happy with your weight?  
 A-39 Do you exercise at least 3 times per week?  
 A-40 Do your daily meals include fruits and vegetables?  
 A-41
Is your BMI greater than 25? To find out, enter your information into the table below and press calculate.
Body Mass Index
 
 

Thank you for completing the Whole Child Profile.

In order to match your family's needs to services and give you a list of providers who can help you, please provide the following confidential information about your family. Your Whole Child Profile will only be shared with your permission.

You only have to fill out the boxes marked "required" to get basic information about providers. However, information such as name, address, and telephone number is essential if you wish to receive specific services.
 
Adults
List each adult living in your household on the rows provided below.
 
First Name
Middle Name
Last Name
Suffix
Sex
Employment Status
(Required)
Race / Ethnicity
   Person Completing Profile
Adult 1
Adult 2
Adult 3
Adult 4
Adult 5
Children
List each child living in your household on the rows provided below. Please list the youngest child first.
First Name
Middle Name
Last Name
Suffix
Sex
Date of Birth
(Required)
Race / Ethnicity
Child 1
Child 2
Child 3
Child 4
Child 5
Contact Information
Address
City
Zip Code
(Required)
Email Address
Best Phone Number to Contact You (Required If Advisor Requested)
Best Time to Contact You
Special Contact Instructions
I prefer to communicate using
Family Income (Required)
Under $10,000      $10,000 - $23,000      $23,001 - $36,000      Over $36,000
Confidentiality

The Whole Child Connection respects the need for confidentiality regarding the personal information you submit on your Whole Child Profile. All of the information in this profile is confidential and will only be shared with your permission with those you designate. Unauthorized users will not have access to your data.
 
User Name And Password

You must create a User Name and Password if you would like to view your Whole Child Plan at a later time, or if you would like to receive assistance from a Whole Child Advisor.

Please use words that you will remember, and write them down for future reference.
   
User Name      Password
   
PLEASE PRINT YOUR WHOLE CHILD PROFILE FOR YOUR RECORDS, THEN CLICK ONCE on the "Submit" button. Clicking the button more than once will cause a system error to occur.
   
 
I give permission to the Whole Child Coordinator to send me additional information about the Whole Child Connection and to contact me to determine how well the Whole Child Connection has met the needs of my children 0 to 18.
   
 
 

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