Primary Caregiver ☐ ☐ ☐ is: Mother Father Foster Parent/Guardian ☐ Other Specify: Person Interviewed: Primary language of the household: What is the primary source of income for the family? Does family receive: ☐ WIC ☐ Food Assistance ☐ Medicaid/Medicare/SSI/SSDI ☐ MI Child ☐ Maternal Infant Health ☐ Public Housing Other: Social service agency support, food pantry etc Transportation Assistance ☐ ☐ Does the family own or rent the property? Own Rent If rented: ☐ ☐ Owners Name: Address: Phone #:
Primary Caregiver is: ☐ Mother ☐ Father ☐ Foster Parent/Guardian ☐ Other Specify: Person Interviewed: Primary language of the household: What is the primary source of income for the family? Does family receive: ☐ WIC ☐ Food Assistance ☐ Medicaid/Medicare/SSI/SSDI ☐ MI Child ☐ Maternal Infant Health ☐ Public Housing ☐ Other: Social service agency support, food pantry etc ☐ Transportation Assistance Does the family own or rent the property? ☐ Own ☐ Rent If rented: Owners Name: Address: Phone #:
EBL%20Case%20Management%20Guide%20Updated%201_24_2017.docx