Novinway Family Intake | Internal v3
Internal interviewer form. Use this during the live conversation. Ask the questions that are relevant and record what the family shares. All fields are optional. If the call ends early or a topic is not covered, leave it blank or mark the section for follow-up. Questionnaire version 3.0 | August 2026
PART 1 OF 10 · 0–7 MINUTES
FOR SYD Thank the family, explain why the questions matter, and invite corrections at any point.
Who is with us today, and what is each person’s relationship to the child?
Optional prompt: Record every participant and relationship.
Primary contact and legal guardians — name, relationship, phone, and email
Prompts: Record the primary contact first, then any additional legal guardians or decision-makers.
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.
Does Part 1 need follow-up?
PART 2 OF 10 · 7–20 MINUTES
Health, home & care history
FOR SYD Gather the health, home, current-plan, daily-assistance, and prior-care facts needed for safe respite care.
Does the child have any allergies?
Is there any health condition, urgent event, mobility need, or equipment a Care Specialist must understand?
Are there medications relevant to the care window, including medication that may be due or emergency medication?
What should happen if the child becomes ill, has an unusually difficult day, or may need the visit to end early?
Optional prompts: Parent contact, pickup or handoff, urgent signs, and practical steps.
Are there off-limit areas or features of the home that require special supervision?
Optional prompts: Exterior doors or windows, stairs, pool or water, trampoline, balcony, alarms, cameras, medications, chemicals, tools, smoke or vaping, or other staff-environment concerns.
Is there a firearm or other weapon in the home?
Are there custody, access, restraining-order, or authorized-pickup restrictions the Care Specialist must follow?
Will the Care Specialist transport the child or accompany them on public transportation or on foot?
Which current plans or school/provider guidance may be relevant to care?
Does the child need hands-on assistance beyond what is typical for their age?
Hands-on assistance details
Prompts: Toileting, bathing, dressing, eating, personal hygiene, transfers, walking, or mobility; when help is needed; who provides it now; and anything requiring scope review.
Internal: Record enough to request the right documents. Carry forward the relevant guidance later; do not ask the family to list the same plans again.
Are there any diagnoses or evaluations you want to share that would help us understand the child?
Optional. Use the family’s language. Record only what helps Novinway understand the child or prepare care; do not treat a diagnosis as the whole profile.
Does Part 2 need follow-up?
PART 3 OF 10 · 20–30 MINUTES
FOR SYD Understand why help is needed now, what relief would change, and whether navigation support may help.
What brought you to Novinway, and where do you need the most help right now?
Optional prompts: Capture the family’s own wording.
What would reliable care make possible for the child and for the rest of the family?
Optional prompts: Upcoming work, school, caregiver, or family changes; any deadline that makes timing important.
Tell me briefly about the child’s care history: who helps now, who has connected well, what worked, and why any successful arrangement ended.
Prompts: Current caregivers, relatives, providers, what built trust, and what made a successful relationship last.
What has not worked in past care, and what should Novinway avoid repeating?
Prompts: Confidence, communication, reliability, boundaries, safety, age-respectful treatment, family guidance, and avoidable management burden.
What has managing care required from you, and what would genuine relief look like?
Prompts: Listen for the practical and emotional load Novinway should reduce, and what would make support feel like more work.
Syd’s 30-second reflection
Optional prompts: Summarize why the family needs care, what it should change, and what past care taught them. Read it back and capture corrections.
Did the family confirm the reflection?
Outside respite care, are there administrative tasks or system problems that are taking too much time or have gotten stuck?
Prompts: Records, services, referrals, waitlists, scheduling, providers, school or IEP follow-up, insurance reimbursement, benefits, applications, deadlines, or other coordination.
Would you like Novinway to follow up about navigation support?
PART 4 OF 10 · 30–42 MINUTES
FOR SYD Build a positive, specific picture of the child. Ask the main questions aloud and use prompts only when helpful.
What are they good at, and what are they proud of?
Prompts: Skills, effort, humor, relationships, independence, creativity, persistence, and what they feel proud of.
Where do they like to go, and what do they enjoy doing in the community?
Prompts: Parks, stores, restaurants, sports, classes, walks, climbing, familiar routes, or other outings.
What foods or snacks do they especially enjoy, and what does a really good day look like for them?
Prompts: Favorite foods and drinks, signs of enjoyment, preferred pace, people, places, and what makes the day feel successful to them.
What are they interested in right now at home?
Prompts: Favorite toys, games, characters, media, comfort items, collections, hyperfixations, repeated themes, and favorite places at home.
Does Part 4 need follow-up?
PART 5 OF 10 · 42–50 MINUTES
FOR SYD Map how the child understands and communicates. Focus on what a Care Specialist must do in real time.
How does the child communicate?
What do they understand, and how should someone speak, explain things, or offer choices?
Prompts: Processing time, wording, one step at a time, visual support, choices, and whether repeating helps or makes things harder. Do not equate limited speech with limited understanding.
What should someone do when they do not understand the child?
Prompts: Pause, check context, offer the communication system, confirm meaning, avoid guessing, and repair the interaction.
For each of the following, how does the child show it: yes, no, stop, finished, help, break, food, drink, bathroom, pain, illness, fear, or overload?
Prompts: Walk through each function. Record the practical signal a Care Specialist must recognize; this is not a pick-one list.
How does their communication change when they are tired, upset, ill, or overloaded?
Prompts: What becomes easier to miss, what people commonly get wrong, and what helps repair a misunderstanding.
Do they use AAC, typing, a communication board, or another system that requires partner training?
Part 5 section notes — anything else from this part?
Optional. Use this for context that does not fit another field. It stays tied to Communication in structured exports.
Does Part 5 need follow-up?
PART 6 OF 10 · 50–65 MINUTES
FOR SYD Start with dislikes and early signs, then ask every standard safety screen directly. Consolidate risks that share the same pattern or response.
What do they dislike or find uncomfortable, and what are the earliest signs that they are becoming overwhelmed or upset?
Prompts: Noise, light, touch, movement, textures, crowds, temperature, demands, waiting, transitions, people, places, and the earliest visible changes.
What helps them stay comfortable, regulate, or recover?
Prompts: Space, company, movement, sensory tools, comfort items, preferred activities, communication support, what helps early, what helps afterward, and what makes things worse.
Direct safety screen Say: “I ask every family the same short set of safety and support questions. Some may not apply to your child. We ask them so we can plan safely, make a thoughtful match, and prepare the Care Specialist well.” Offer a brief pause first if the family seems tired.
Is there a history of elopement, bolting, hiding, or unexpectedly leaving supervision?
Is there a history of aggression toward another person, such as hitting, kicking, biting, scratching, pushing, or throwing objects?
Is there a history of self-injurious behavior, such as hitting, biting, scratching, or banging their head?
Have they thrown dangerous objects or damaged property in a way that could hurt someone?
Do they put or swallow nonfood or unsafe items?
Are there serious risks involving climbing, water, streets, traffic, or vehicles?
Have they made statements or communicated intent about harming themselves or someone else?
Do they ever require uninterrupted line-of-sight or one-to-one supervision for safety?
Has anyone used blocking, restraint, protective equipment, or a formal crisis response with them?
Do any plans identified earlier address the safety concerns we just discussed?
Internal checkpoint: Capture minimum safety facts for every positive screen. Deepen the highest-severity or most likely items during the call. If time is insufficient, arrange focused follow-up before matching or training. Reflect back the response plan and ask the family to correct it.
Part 6 section notes — anything else from this part?
Optional. Use this for regulation or safety information that does not fit another field.
Does Part 6 need follow-up?
PART 7 OF 10 · 65–75 MINUTES
What care should look like
FOR SYD Walk through the visit from handoff to handoff. Use earlier answers instead of asking for the same facts again.
Walk me through an ideal visit, from the beginning handoff to the end.
Prompts: Arrival, transition, activities, the Care Specialist’s role, what to initiate, when to follow the child’s lead, independent time, routines, flexibility, and the ending handoff.
Would weekend, school-break, or seasonal care look meaningfully different?
Will bathroom routines occur during care?
Will meals or snacks occur during care?
Is there any history of choking or swallowing difficulty?
Are there food-related behaviors that affect how meals or snacks should be supervised?
Will bedtime or sleep routines occur during care?
Will visits include outside play or community activities?
Internal checkpoint: Briefly reflect back the care window, communication, and relevant routines. Ask, “Is anything there backwards or missing?” If bathroom support may exceed age-typical childcare, gather the practical details and flag it for scope review.
Part 7 section notes — anything else from this part?
Optional. Use this for visit or routine information that does not fit another field.
Does Part 7 need follow-up?
PART 8 OF 10 · 75–82 MINUTES
Schedule & practical setup
FOR SYD Lock down when and where care is needed, who is reachable, and the practical setup for visits.
Which days may require care?
List each care block: day, start time, end time, frequency, and how fixed or flexible it is.
Optional prompts: List each recurring block. Note school-term, seasonal, weekend, school-break, or occasional needs.
Overall expected frequency
How much notice can the family usually provide, and what can or cannot change?
Optional prompts: Allowable shifts, minimum notice, backup schedule, and what can or cannot change.
Earliest desired start date
Hard start deadline, if any
Where will the parent or guardian be during care, how should Syd reach them, and should the secondary contact be the backup if the primary contact cannot be reached?
Optional prompts: Record the contact order and who has authority to make decisions during the visit.
If something seems wrong but is not yet an emergency and no one answers, what should the Care Specialist do?
Optional prompts: Treat this as part of the parent-contact and backup plan.
Will more than one child be in the Care Specialist’s care?
How should the Care Specialist balance active engagement, following the child’s lead, supervision, and independent time?
Prompts: What the Care Specialist should initiate, what should follow the child’s lead, what requires parent approval, what should not become a demand, and how much independent time is safe and comfortable.
What household rules should the Care Specialist follow, and what information do you want after a visit?
Optional prompts: Screens and devices; food outside meals; rooms and doors; going outside; personal phone use; photos, video, and social media; preferred post-visit update; level of detail; urgent versus routine communication.
Part 8 section notes — anything else from this part?
Optional. Use this for schedule or practical setup information that does not fit another field.
Does Part 8 need follow-up?
PART 9 OF 10 · 82–87 MINUTES
FOR SYD Ask one matching question, use the mandatory requirement and exclusion probes, then capture any missing plans or permissions needed for matching.
Based on who has connected well before, what matters most in the match?
Mandatory probes if not already answered: Is anything absolutely required? Is there anything that would rule someone out? Then prompt as needed for personality, confidence, language, gender preference, driving, physical ability, smoke or animal exposure, availability, communication experience, and identified safety needs.
Which plans or guidance recorded in Part 2 still need to be collected or clarified before matching?
Permission to contact a provider or other person for relevant guidance
What would success look like after the first month?
Capture: Describe the practical change for the child and family.
Part 9 section notes — anything else from this part?
Optional. Use this for context that does not fit another field. It stays tied to Matching, training & first session in structured exports.
PART 10 OF 10 · 87–90 MINUTES
FOR SYD Summarize the meaning, invite corrections, confirm sensitive-information handling, and explain the next steps.
Reflect back: why the family needs care and what it should change; who the child is; communication; the shape of a visit and relevant routines; regulation and safety; health, home, or scope questions; matching and training priorities; schedule and start date.
Did I understand that correctly? What did I miss or get wrong?
Record the family’s correction in their own words.
Is there anything sensitive you shared that you want us to discuss with you before including it in materials provided to a Care Specialist?
Explain that Novinway includes only what the Care Specialist needs. Do not promise to withhold information required for safety, scope review, training, or effective care; explain who needs access and why.
What is the most important thing you want us to carry forward from this conversation?
Use the family’s own words.
What questions does the family have?
Record the answer given and any promised follow-up.
Part 10 section notes — anything else from this part?
Optional. Use this for context that does not fit another field. It stays tied to Summary, corrections, questions & next steps in structured exports.
