ReLief Family Advocacy Program
How did you hear about Rebound/ReLief?
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Annual Household Income
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$0-$20,000
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
$60,000-$70,000
$70,000-$80,000
$80,000+
How many live in your household (including yourself)?
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Please Select
1
2
3
4
5
6
7
8
9
10
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Please briefly describe the type of advocacy that you are seeking (i.e parent coaching, referrals to basic services, CPS and custody support, etc.).
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First Adult Information
Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Preferred Method of Contact
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Phone
Text
Email
Email
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example@example.com
Gender
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Woman
Man
Non-Binary/Gender Fluid
Prefer not to say
Pronouns
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He/him/his
She/her/hers
They/them/theirs
Other
Primary Language Used in Your Household
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English
Spanish
Other
Race (check all that apply)
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American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are you Hispanic or Latino?
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Yes
No
Marital Status
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Single
Married
Divorced
Widowed
What is your relation to the children listed below?
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Emergency Contact Person (other than self)
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First Name
Last Name
Emergency Contact Phone Number
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Please enter a valid phone number.
Who is authorized to pick up your child in the event of an emergency?
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Please indicate which, if any, of the following services you are currently receiving:
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Apple Health/Medicare
Woman, Infants, and Children Program (WIC)
Food Stamps/EBT
Washington State Housing Assistance
I am not receiving any of these services
(Optional) Are you currently impact by any of the following?
Houselessness/Unstable housing
Mental illness
Domestic violence
Child(ren) in foster care/in care of others
Substance dependence
(Optional) Growing up, did you experience any of the following?
Teen pregnancy
Being raised by someone in the armed forces
Being raised by a single parent
Foster care/being raised by someone other than your biological parents
Sexual abuse
Experimentation with drugs and/or alcohol
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Next
Second Adult Information
Leave blank if only one adult is seeking advocacy.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Method of Contact
Phone
Text
Email
Gender
Man
Woman
Non-Binary/Gender Fluid
Prefer not to say
Pronouns
He/him/his
She/her/hers
They/them/theirs
Other
Primary Language Used in Your Household
English
Spanish
Other
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are you Hispanic or Latino?
Yes
No
Marital Status
Single
Married
Divorced
Widowed
What is your relation to the children listed below?
Please indicate which, if any, of the following services you are currently receiving:
Apple Health/Medicare
Woman, Infants, and Children Program (WIC)
Food Stamps/EBT
Washington State Housing Assistance
I am not receiving any of these services
(Optional) Are you currently impact by any of the following?
Houselessness/Unstable housing
Mental illness
Domestic violence
Child(ren) in foster care/in care of others
Substance dependence
(Optional) Growing up, did you experience any of the following?
Teen pregnancy
Being raised by someone in the armed forces
Being raised by a single parent
Foster care/being raised by someone other than your biological parents
Sexual abuse
Experimentation with drugs and/or alcohol
Back
Next
First Child Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
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American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
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Yes
No
What grade are they in?
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Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
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Next
Second Child Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
Yes
No
What grade are they in?
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Back
Next
Third Child Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
Yes
No
What grade are they in?
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Back
Next
Fourth Child Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Boy
Girl
Non-Binary/Gender Fluid
Other/Prefer not to say
Race (check all that apply)
American Indian or Alaskan Native
Asian
Black, African-American, or Afro-Latino
Native Hawaiian or other Pacific Islander
White
Are they Hispanic or Latino?
Yes
No
What grade are they in?
Please Select
N/A
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Please briefly describe the type of advocacy that you are seeking (i.e parent coaching, referrals to basic services, CPS and custody support, etc.)
Back
Next
Informed Consent for Recording
We must request your permission to record the above persons sessions on audio and/or video file(s). The purpose of recording is to help us better serve you and to review and evaluate our techniques. No recording will be done without your prior knowledge and consent. At any time, you may request a copy of these recordings for your own records. Viewers/listeners of the video/audio file(s) may include Rebound Families staff for the purposes of data tracking. All viewers/listeners of the video/audio file(s), including myself, are bound by the ethical standards of our organization. The video/audio file(s) will be treated with confidentiality by being stored on a password protected computer and will be destroyed at the termination of advocacy support. By signing below, you are stating that you have read and understood the Informed Consent for Recording and that you are permitting Rebound Families to video/audio record our session(s) and review the video/audio file(s) with the aforementioned individuals.
Signature
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