Todays Date
-
Month
-
Day
Year
Date
Woman's Empowerment Intake Form
Full Name
*
Prefix
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Disability
*
Yes
No
E-mail
*
Last Four of Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
If we cant reach you who can we contact?
Please enter you emergency contact name, phone number and relationship
Are you a Veteran
Yes
No
Number of people in household that you are responsible for (i.e. Children, partner, spouse)
*
Please Select
1
2
3
4
5
6
7
8
9
Please estimate your annual Income
*
Employment
*
Please Select
Full Time
Part Time
Self Employed
Unemployed
Not Looking for a job
Looking for a job
If employed; List Name of employer Type of work Days and Hours worked
Gender
*
Male
Female
I AM
*
Please Select
African American American
White
Asian
Bi/Multiracial/Mixed
Other
I AM
*
Hispanic
Non Hispanic
Marital Status
*
Please Select
Single
Married
Committed
Divorced
Separated
Other
Are you a Mother OR Caregiver
*
Yes
No
Are you pregnant
*
Yes
No
Due Date
-
Month
-
Day
Year
Date
Name of Childs Father
First Name
Last Name
US Citizen
*
Yes
No
How many Children do you have?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
How many of your children are under 18
Please Select
1
2
3
4
5
6
7
8
9
Children's Information
Childs Name
Date of Birth
School Grade
Gender
Daycare Provider
Child 1
Child 2
Child 3
Child 4
Housing: Are you currently?
*
Renting an apt/home
Living with Family/Friends
Buying a home
Homeless
Are you receiving any of the following
*
Child Support
Child Care Assistance
Food Stamps
Medical Assistance
Low Income Subsidized Housing
SSI/SSDI
Salary/Wages
Unemployment Insurance
TANF
NONE
Have you ever been Arrested?
*
Yes
No
Have you ever been In Jail?
*
Yes
No
Have you ever been In DOC/Prison?
*
Yes
No
What type of convictions do you have
Please Select
Felony
Misdemeanor
Both Felony and Misdemeanor
Would you like assistance looking for a job?
Yes
No
Are you Head of Household?
*
Yes
NO
How engaged are you with your children?
*
Not at all
Very Little
Somewhat
Very Much
Annual Household Income
*
Please Select
0 - 9,999
10,000 - 14,999
15,000 - 19,999
20,000 - 29,999
30,000 - 39,999
40,000 - 49,999
50,000 - 59,999
60,000 - 69,999
70,000+
Education
*
Please Select
Bachelors
Associates
Technical/Voc Certificate
High School/GED
None
Last Grade Completed
*
List Special Skills and Certifications
Are you currently on
Probation
Parole
Work Release
House Arrest
Do you feel safe in your current relationship?
*
Please Select
Yes
No
Is there a partner from a previous relationship who is making you feel unsafe now?
Please Select
Yes
No
I would like more information on
Please Select
Strong Fathers Class
Getting my High School Equivalency Diploma
Relationship / Marriage Counseling
Up to what age was your father present in the home when you were growing up?
When you were growing up, how involved was your father with you?
Not at all
Very Little
Somewhat
Very Much
Not Applicable
How would you describe the relationship with your father now
Poor
Fair
Good
Very Good
Deceased
Not Applicable
How engaged are you with your children
*
Please Select
Not at all
Very Little
Somewhat
Very Much
Do you currently have an open DCS Case?
Yes
No
RELEASE OF INFORMATION
I understand that my participation in Fathers and Families Center programs, services and activities is voluntary. I certify that all information is accurate and complete. Any information learned about me for this interview or during my involvement in this program may be shared with other FFC staff members and others as appropriate and according to HIPPA guidelines. Further, I understand that information or images/photos about me can be used to promote Fathers and Families Center as long as I am not identified by full name or social security number. Please Sign Below
Please use your finger or mouse to sign Below - FIRST and LAST name
*
Where did you hear About Fathers and Families Center
*
Please Select
Walk IN
Online
Indiana Housing Authority
Other
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