Whole Child Profile Questions
The Whole Child Connection is a simple way to link to all the resources available for children 0-17 and their families. Just complete the Whole Child Profile and find out what our community can offer.

Please answer each of the 41 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 have health insurance / Medicaid for your children?  
 2 Do you have health insurance / Medicaid for the rest of your family?  
 3 Do you have a doctor for your children?  
 4 Do you have a doctor for yourself and the rest of the family?  
 5 Do you have a dentist for your children?  
 6 Are you experiencing any family loss or trauma due to divorce, separation, death, domestic violence, etc?  
 7 Are immunizations / shots up to date for all your children under age6?  
 8 Do you have any concerns about hearing for any of your children?  
 9 Do you have any concerns about vision for any of your children?  
 10 Do you have any concerns about balance for any of your children?  
 11 Do you have any concerns about speech for any of your children under age 6?  
 12 Do you usually run out of money before your food, shelter and clothing needs are met?  
 13 Do you have access to reliable transportation when you need it?  
 14 Do you need information about job placement, training, GED, ESOL or Higher Education classes?  
 15 Does your child like to be hugged and comforted?  
 16 Do your children under age 6 get along with other children?  
 17 Do you have any concerns about the behavior of any of your children under age 6?  
 18 Do you have any concerns about the physical, emotional, social or intellectual development of any of your children under age 6?  
 19 Do you have someone you can depend on when you need help?  
 20 Do you need childcare / preschool for any of your children under age 6?  
 21 Do you feel that you have the skills necessary to help your child do well in school?  
 22 School readiness begins at birth. Do you feel that your children are mentally, physically and emotionally ready to begin kindergarten?  
 23 Are you concerned about adequate nutrition?  
 24 Do you feel safe in your home?  
 25 Do you ever worry about the effect of alcohol and drugs on your family?  
 26 Is your neighborhood a safe place?  
 27 Have you moved more than three times in the last two years?  
 28 Do your children have a safe place to play?  
 29 Does your home have running water?  
 30 Do you currently have utilities available in your home such as gas or electricity?  
 31 Do you have time to think about yourself and your needs?  
 32 Do you want information about activities in your community for your family?  
 33 Do you need information related to Women's Health needs?  
 34 If you are expecting a child, do you have pre-natal care? Do not answer if not applicable.  
 35 Are you caring for a child with special needs/disabilities?  
 36 Are you caring for an adult age 60 or over?  
 37 Would you like information on Housing?  
 38 Are there any specific services that you need to help you with your children under age 6? If YES, please list below with the most important service first.  
 39 Have you experienced any specific barriers to receiving services? If YES, please list them below with the most important barrier first.  
 40 Traditionally services are provided between 8:00am and 5:00pm, Monday through Friday. If you do need services outside that time frame, please specify?  
 41 Are there things that you can and want to do to help other parents in your neighborhood support their young children? If so, please list them below and someone will contact you.  
 

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
Family Income (Required)
Under $10,000      $10,000 - $23,000      $23,001 - $36,000      Over $36,000
 
I give permission for Whole Child Manatee to send me additional information about Whole Child and to contact me to determine how well Whole Child Connection has met the needs of my family.
Confidentiality

The Whole Child Project Manatee 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. All information is confidential. Only you decide who sees your plan. Contact information is required if you are requesting services from a Provider listed in the Whole Child Connection.

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.
   
   
 
 

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