Child Enrollment Online Interview - Big Brothers Big Sisters Kansas City

Thank you so much for taking the time to complete this online interview. Please complete a separate interview for each child you are enrolling.

Questions? Send an email to [email protected].

Basic Info

Child's Name(Required)

First Last

Child's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Name(Required)

First Last

Parent/Guardian Phone(Required)

Parent/Guardian Email(Required)

Was your child previously matched?(Required)

Yes

No

Please answer the questions below about your child's previous match.

In your own words, please share why the previous Match closed.(Required)

What did you like most about the previous Big?(Required)

General Questions

Does your child have siblings or family members enrolled in the program? If so, what are their names?(Required)

Is your child a leader, follower, or a loner with peers/other children?(Required)

Child's Health

Does your child have allergies to any food, plants, animals, insect bites, medications, etc.?(Required)

Are there foods or drinks you limit or don't allow your child to have? If yes, what?(Required)

Does your child have any physical or mental health diagnoses? If yes, what is the diagnosis?(Required)

Is he/she on any medication? If yes, what medication, and how often is it taken?(Required)

What do you do to help manage your child's symptoms?

Does your child have a disability that limits their activity or requires special accommodations or assistance?If yes, what accommodations are necessary for your child?(Required)

Is your child verbal or nonverbal?(Required)

Has your child ever seen a counselor or therapist? If yes, when?(Required)

Do you feel that the service has benefited your child?

Has your child ever been involved with the juvenile justice system?(Required)

If yes, how many times has your child had involvement or contact with the police or juvenile justice system?

If your child is currently involved in the juvenile justice system, is there a case manager, probation or court worker assigned to your child? If yes, please share their name and contact info below.

Does your child have a sibling who has had juvenile justice system involvement?(Required)

Personal Trauma History

To the best of your knowledge, has your child experienced emotional, physical, or sexual abuse in the past? Check all that apply. *(Required)

Emotional

Physical

Sexual

None known

Have you talked to your child about the difference between good touch, bad touch, and confusing touch?(Required)

Have you discussed the topics of sex and puberty?(Required)

Would you be comfortable with a Big answering any questions your child asks on these topics?(Required)

Have you ever been investigated by child protective services for abuse or neglect? If yes, when did this occur, and what was the outcome?(Required)

Has your child witnessed domestic violence or violence in the neighborhood?(Required)

Child's Academic Life

What school does your child attend?(Required)

How long has your child attended this school? If they recently changed schools, why?(Required)

What grade is your child in?(Required)

Does your child receive tutoring, have an IEP, or 504 Plan? If so, please explain.(Required)

Has your child had to repeat a grade?(Required)

Has your child skipped a grade?(Required)

Has your child ever been suspended from school? If yes, why?(Required)

How often would you say your child misses school (for illness, transportation, suspensions, etc.)?(Required)

Is your child often late to school?(Required)

Has your child skipped school in the past? If so, how have you or the school responded in the past?(Required)

What extra-curricular activities is your child involved in? How often do they meet? Examples include: band, student council, art classes, robotics, scouts, sports, etc.(Required)

Parent Information

Are you currently employed or in school? If yes, what is your work/class schedule?(Required)

Where do you work?(Required)

Has your child ever not lived with you? If so, please provide details.(Required)

Are you currently in a relationship? If yes, do you have plans to live together or marry?(Required)

Do you typically date men or women?(Required)

Does your partner live or spend a significant amount of time in your home?

How do your child and partner get along?

What is your child's current family living situation?(Required)

One parent home

Two parent home

Kinship care/foster home

One Parent Home

What is the name of the child's biological parent(s) that is/are not in the home?(Required)

What is the child's relationship with the other parent(s) like?(Required)

What was the relationship status between yourself and your child's other parent (married, in a relationship, casually dating, just friends, etc.)?(Required)

Did you ever live together?(Required)

What was the timeframe of your relationship?(Required)

How frequently do your child and their out-of-home parent spend time together? When did your child last see or talk to them?(Required)

How involved is the out-of-home parent in the child's life (decision making, financially, custody arrangement, etc.)?(Required)

Have you talked to your child's out-of-home parent about enrolling them in BBBS?(Required)

If yes, are they supportive? If not, do you think they will be supportive of your child being matched with a Big?(Required)

Two Parent Home

How long have you and your partner been in a relationship?(Required)

How does your child get along with them?(Required)

Have you talked to their other parent about enrolling them in the BBBS program? If yes, are they supportive? If not, do you think they will be supportive of your child being matched with a Big?(Required)

Kinship Care/Foster Home

How long has the child been in your care?(Required)

Do you know why they were removed from the home?(Required)

Does the child have contact with their biological parent(s)? Are there reunification plans? *(Required)

Additional Information

Is there anyone closely associated with your family that may pose a safety risk to your child's future Big or anyone involved with the BBBS program?(Required)

Does the child have a parent or loved one currently in jail, state, or federal prison?(Required)

Yes

No

Please answer the following

What is their name and their relationship to your child?(Required)

What was the nature of the offense and how long is their sentence?(Required)

How long have they been incarcerated?(Required)

What does the child know about the parent/loved one being incarcerated?(Required)

Will the child reconnect with this person after their release?(Required)

Do you anticipate that the child will want to talk to their Big about their incarceration?(Required)

Home/Neighborhood Description

How long have you lived in your current home, and how long do you plan on staying here?(Required)

If you are moving soon, when and to what location?

Is their a specific religion or faith practiced in the home?

Anything else you would like to add?

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