Family Needs Assessment Form

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Because We Care Initiative / Family Needs Assessment Form

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Patient's Folder No.

Date

GENERAL INFORMATION

Name of Child

Sex

Male

Female

Date of Birth

Diagnosis

Estimated total cost of treatment (Ghc)

Accompanying person

Mother

Father

Other (specify)

Family’s Region & Town of residence

Name of Father

Name of Mother

Region of residence

Telephone number

Occupation (tick relevant score)

Expatriate, Business Person, Politician = 1

Professional, High level civil servant, medium scale trader = 2

Middle-level civil servant, teacher, technicians, skilled artisans = 3

Unskilled worker/Petty trader/Apprentice = 4

Unemployed/Unable to work due to child's illness = 5

Deceased/Uninvolved in child's care = 6

Highest level of education completed (tick relevant score)

University = 1

Technical/Teacher Training College = 2

Senior Secondary = 3

Junior Secondary = 4

Primary/No formal education = 5

Deceased/ Uninvolved in child's care = 6

Average (total) monthly household income (GHc)

Additional relevant information (if applicable)

Support Requested

Check all relevant and indicate cost (Ghc)

Tissue Biopsy/Histopathology

Bone Marrow Aspirate

CT Scan

MRI

Ultrasound

Blood Products/Blood Bank Fees

Other

Total Amount Requested (Ghc)

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