M1-THEO

MIECHV ENROLLMENT

Index Parent

Enrollment Date:	/ / 20

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Index Parent’s ID #:

First, Middle, and Last Name of Index Parent:

First	Middle	Last

Parent Client Record/Demographics:

(Questions A-E will ONLY be entered on the New Client screen during the Application/Enrollment process in THEO – NOT in the M1 Survey)

A.	Date of Birth:	/ /

B.	Gender:	Female	Male	X (Non-binary)

C. Primary Language:	English	Spanish	Other language:

D.	Ethnicity:	Not-Hispanic or Not-Latino/a	Hispanic or Latino/a Declined to self-identify Unknown

E.	Race (Check all that apply):

American Indian/Alaska Native	White/Caucasian

Asian	Unknown

Black or African American	Declined to self-identify

Native Hawaiian/Other Pacific Islander

Pregnancy:

F. Enter in M1 Survey: Mother Pregnant at Enrollment? Yes → Go to Question F1.	No

F1. Enter during Client Application/Enrollment process: If Pregnant, Expected Delivery Date: / / 20

Questions about Family:

Which members of your (index parent’s) family are currently serving or formerly served in the

military – active or reserve? (Check all that apply.)

Index parent	Father of child

Index parent’s spouse	Mother of child

Index parent’s parent(s)	None

2.	Additional Children in Home? No → Go to Question 3.	Yes:

(Birth – 18 yrs old; other than Index Child; living in the home)	DOB / /

DOB / /

DOB / /

M1-THEO

MIECHV ENROLLMENT, continued

Index Parent	ID# ______________

Questions about Index Parent:

3.	Marital Status:

Single/Never Married	Separated/Divorced/Widowed

Married	Not Married but living together with partner

4.	Relationship to Index Child:

Biological mother	Biological father	Other caregiver

5.	Index Parent’s Current Health Insurance status:

Not insured	State Children’s Insurance Program (SCHIP)

Private or employer’s insurance	TRICARE or other military health care

OHP/Medicaid	Other insurance:

CAWEM/CAWEM Plus

6.	Educational Attainment:

Currently enrolled in middle school	Some college/training

Currently enrolled in high school	Associate’s degree

Less than high school diploma	Bachelor’s degree or higher

High school diploma/GED	Other:

Technical training or certification

7.	Current Education/Training status:

Enrolled student/trainee (full or part-time)	Not enrolled

8.	Current Employment status:

Employed full time	Employed part time	Not employed

9.	Does anyone living in the household have a history of substance abuse or need substance abuse treatment?

Yes	No	Unknown

10.	Does Index Parent currently use tobacco products? (Tobacco includes combustibles [cigarettes, cigars, pipes, hookahs, and bidis], non-combustibles [chew, dip, snuff, snus, and dissolvables], and ENDS)

Yes→ Go to Question 10a.	No→ Go to Question 11.	Unknown→ Go to Question 11.

10a. If yes, is parent currently receiving tobacco cessation services?

To meet Tobacco Cessation Referral Measure: Record Date Referred to Tobacco Cessation Services within 3 months of Enrollment on M2B-MIECHV Referrals Tracking & Follow-up form.	Yes

No

Unknown

11. Does anyone else living in the household use tobacco products? Yes	No	Unknown

M1-THEO

MIECHV ENROLLMENT, continued

Index Parent	ID# ______________

12.	Has anyone living in the household had a history of child abuse or neglect & involvement with child welfare services either as a child or as an adult?

Yes	No	Unknown

13.	Has a doctor or health professional ever told you (index parent) that your child/any of your children has any developmental delay or developmental disability?

Yes	No	Unknown

14.	Is there anyone in your household (including adults and children) who had/has a low student achievement level?

Yes	No

15. Last month, what was your (parent’s/guardian’s) gross TOTAL HOUSEHOLD income from employment and any benefits you receive? All information will be kept private and will not affect any services you (parent) are now getting.

Include all of these income sources:

Paycheck or money from a job	Benefits such as TANF or SSI	Money from a business, fees, dividends, or rental income	Child support or alimony

Social security, workers’ compensation, disability, veteran benefits or pensions	Unemployment benefits

$250 or less

$251 - $500

$501 - $750

$751 - $1,000

$1,001 - $1,250	15a. Number of adults in household:	Adults

$1,251 - $1,500	15b. Number of children in household: Children

$1,501 - $1,750

$1,751 - $2,000

$2,001 - $2,250

$2,251 - $2,500

$2,501 - $2,750

$2,751 - $3,000

$3,001 or more

Don’t Know

16.	Current Housing Status:

You own or share your home, condominium or apartment

You rent or share your home or apartment

You live in public housing

You live with a parent or family member

You have a different living arrangement, but are not homeless

You are homeless and sharing housing

You are homeless and living in an emergency or transition shelter

You are homeless and living in some other arrangement