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Novinway Family Intake | Internal v2

Internal interviewer form. Use this during the live conversation. Ask the questions that are relevant and record what the family shares. If the call ends early or a topic is not covered, leave the field blank or mark the section for follow-up. You can submit an incomplete intake and return to it later. Questionnaire version 2.0 | August 2026
PART 1 OF 10 · 0–7 MINUTES

Opening & basics

FOR SYD Thank the family, explain why the questions matter, and invite corrections at any point.

Intake date

Interviewer

A
B
C

Who is with us today, and what is each person’s relationship to the child?

Optional prompt: Record every participant and relationship.

Child’s full legal name

Name the child uses

Child’s date of birth

Child’s age

Child’s pronouns

Primary contact and legal guardians — name, relationship, phone, and email

Prompts: Record the primary contact first, then any additional legal guardians or decision-makers.

Street address

City, state, and ZIP code

Who lives in the home, and who else is regularly present or providing support?

Optional prompts: Sibling names and ages; whether a sibling helps with care; relatives, sitters, therapists, household employees, roommates, or frequent guests.

What languages, cultural or religious practices, identity considerations, or household practices should a Care Specialist understand?

Optional prompts: Use the family’s own language. Record only what is useful for respectful, effective care.

Secondary contact — name, relationship, phone, and email

Record the person Syd should contact if the primary contact is unavailable. This may differ from the during-care emergency backup.

Part 1 status

A
B