FEC RESPONIBLE FATHERHOOD INITIAL ASSESMENT FORM
Date
-
Month
-
Day
Year
Date
FATHER APPLICANT
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county do you live in ?
Phone Number
-
Area Code
Phone Number
Email
example@example.com
EMPLOYMENT & EDUCATION HISTORY
ARE YOU CURRENTLY EMPLOYED
Yes
No
Other
HOW LONG BEEN ON / OFF JOB
GROSS MONTHLY INCOME?
TYPE OF WORK?
HIGH SCHOOL DIPLOMA/GED?
Yes
No
Other
HIGHT LEVEL OF EDUCATION?
Please Select
High School-No Diploma
High School Diploma / GED
Some College-No Degree
Vocational /Technical School
Associates Degree
Bachelors Degree
Master /Graduate Degree
Doctoral / PHD Degree
DO YOU HAVE A VALID DRIVERS LICENSE?
Yes
No
Other
DO YOU HAVE YOUR OWN TRANSPORTATION?
YES
NO
DO YOU HAVE JOB PLACEMENT?
YES
NO
DO YOU HAVE SKILLS PLACEMENT?
YES
NO
DO YOU HAVE CAREER DEVELOPMENT?
YES
NO
DO YOU HAVE RESUME AND INTERVIEW PREPARATION?
YES
NO
DO YOU HAVE FINANCIAL LITERACY TRAINING?
YES
NO
HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE U.S. ARMED FORCES, RESERVES, OR NATIONAL GUARD?
YES
NO
PARENTING & CO-PARENTING ASSISTANCE
HOW MANY CHILD(REN) AGES 17 AND YOUNGER DO YOU HAVE ?
WOULD YOU LIKE TO ENHANCE YOUR PARTICIPATION IN YOUR CHILD(REN) LIVES
YES
NO
HAS PATERNITY BEEN ESTABLISHED BY THE COURTS?
YES
NO
WHEN WAS THE LAST TIME YOU HAD TIMESHARING/VISITATION WITH THE CHILD(REN)
TIME SHARING OR VISITATION WITH YOUR CHILD(REN) WAS/IS DETERMINED BY
Please Select
Please Select
Child(ren) Mother
Mutual Agreement
Temporary Court Order
Final Court Order
No Visitation / Timesharing
ARE YOU CURRENTLY IN COURT FOR PATERNITY OR DISSOLUTION OF MARRIAGE CASE?
YES
NO
ARE YOU REQUIRED TO HAVE SUPERVISED TIMESHARING/VISITATION WITH CHILD(REN)?
YES
NO
DO YOU WANT TO MODIFY YOUR EXISTING TIMESHARING OR PARENTING PLAN ?
YES
NO
WOULD YOU LIKE TO ENROLL IN A PARENTING OR CO-PARENTING CLASS?
YES
NO
WOULD YOU LIKE TO PARTICIPATE IN MEDIATION TO TRY TO RESOLVE ANY ISSUES?
YES
NO
DO YOU REQUIRE ANY THERAPY OR REUNIFICATION SERVICES WITH YOUR CHILD(REN) ?
YES
NO
CHILD SUPPORT
ARE YOU A NON-CUSTODIAL FATHER WITH A CHILD SUPPORT ORDER IN EFFECT?
YES
NO
ARE YOU CURRENTLY MAKING CHILD SUPPORT PAYMENTS ?
YES
NO
HOW MUCH IS YOUR MONLY CHILD SUPPORT OBLIGATION?
DO YOU OWE BACK CHILD SUPPORT
YES
NO
HOW MUCH DO YOU OWE IN TOTAL BACK CHILD SUPPORT (ESTIMATE)?
IS YOUR DRIVER’S LICENSE SUSPENDED DUE TO CHILD SUPPORT
YES
NO
ARE YOU INTERESTED IN PARTICIPATING IN THE DIVERSION PROGRAM FOR SUSPENDED DRIVER’S LICENSE FOR CHILD SUPPORT VIOLATIONS?
YES
NO
COURT DIVERSION SUPPORT ASSISTANCE
DO YOU NEED LEGAL & EMOTIONAL SUPPORT?
YES
NO
DO YOU NEED LEGAL ORIENTATION & EDUCATION ASSISTANCE?
YES
NO
DO YOU NEED MEDIATION & CONFLICT RESOLUTION ASSISTANCE?
YES
NO
DO YOU NEED DIVERSION PROGRAM SUPPORT?
YES
NO
EMOTIONAL, HEALTH & WELLNESS SUPPORT SERVICES
DO YOU NEED FOOD ASSISTANCE?
YES
NO
DO YOU NEED HOUSING ASSISTANCE?
YES
NO
DO YOU NEED CHILD CARE ASSISTANCE?
YES
NO
DO YOU NEED HEALTHCARE SERVICES?
YES
NO
DO YOU NEED MENTAL OR EMOTIONAL SUPPORT?
YES
NO
DO YOU NEED ACCESS TO SUBSTANCE USE SERVICES?
YES
NO
DO YOU NEED ACCESS TO FAMILY COUNSELING SERVICES?
YES
NO
CLIENT DEMOGRAPHICS
ARE YOU A RECIPIENT OF SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)?
YES
NO
ARE YOU A RECIPIENT OF TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF)?
YES
NO
ARE YOU A RECIPIENT OF RE-EMPLOYMENT ASSISTANCE?
YES
NO
ARE YOU AN INCARCERATED OR PREVIOUSLY INCARCERATED FATHER WITHIN LAST 2 YEARS?
YES
NO
ARE YOU A RESIDENT IN ONE OF FLORIDA’S 427 OPPORTUNITY ZONES?
YES
NO
ARE YOU PARTICIPATING IN THE BATTERERS INTERVENTION PROGRAM (BIP)?
YES
NO
ARE YOU INVOLVED IN A DEPENDENCY (CHAPTER 39) PROCEEDING FOR YOUR CHILD(REN)?
YES
NO
HAVE ANY OF YOUR CHILD(REN) AGES 17 AND YOUNGER BEEN FOUND DEPENDENT OR TAKEN?
YES
NO
DO YOU HAVE ANY CRIMINAL ARRESTS OR CONVICTIONS ?
YES
NO
ARE YOU PARTICIPATING IN THE LICENSED-TO-DRIVE DIVERSIONARY PROGRAM CHILD SUPPORT?
YES
NO
EMERGENCY OR URGENT NEEDS
DO YOU FEEL LONELY OR ISOLATED FROM THOSE AROUND YOU?
YES
NO
DO YOU HAVE FOOD FOR TONIGHT?
YES
NO
DO YOU HAVE A PLACE TO SLEEP TONIGHT?
YES
NO
IN THE LAST 6 MONTHS DO YOU LACK TRANSPORTATION TO GET TO WORK, APPTS, ETC ?
YES
NO
IN THE LAST 6 MONTHS HAS THE UTILITY COMPANIES THREATEN TO SHUT OFF SERVICES?
YES
NO
ARE YOU WORRIED THAT YOU MAY NOT HAVE STABLE HOUSING IN THE NEXT 30-90 DAYS?
YES
NO
ADDITIONAL INFORMATION & NOTES
REFERRED BY:
Please Select
Please Select
Batters/Domestic Violence Program
Career Source (Central Florida)
Chapter 39 (Child Dependency/Welfare)
Child Support Enforcement
Faith-Based Referral
Fathers Returning To Society
Law Enforcement Voluntary Referral
Non-Custodial Fathers
Probation / Parolee Department
SNAP- Supplemental Nutritional Assistance Program
State Attorney Diversion Office
Voluntary Enrollment
Submit
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