iDAD Comprehensive Needs of Fathers Program Referral & Intake Form
Please fill out the intake form.
Referral For (I am filling this form out for)
Self
Other
Referring Person (if referral is for self complete below)
First Name
Last Name
Full Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
No email?
I do not have an email and would like help getting one.
Address (If homeless or between permanant residence enter "N/A" in each field
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
How many children do you have?
Are you (or the father being referred) currently employed?
*
Yes
No
No, but would like assistance with employment
Are you (or the father being referred) currently receiving TANF or SNAP services?
*
Yes
No
No, but would like assistance with TANF or SNAP services
Do you (or the father being referred) currently have child support orders?
*
Yes
No
If you (or the father being referred) currently has child support orders, are you (is he) up-to-date with child support?
Yes
No
Do you (or the father being referred) meet any of the following:
*
Father of children 17 and younger
Live in St. Lucie or Indian River County
Receives / Needs TANF or SNAP services
Receives / Needs re-employment assistance
Previously incarcerated
Non-custodial Father with child support orders
None of these apply
Type of Service Needed
Housing Assistance
Financial Support
Counseling
Employment Assistance
Food Assistance
Healthcare
Child Support Assistance
I am just interested in the Fatherhood program
Other
Photo & Video Release Waiver
I hereby grant the iDAD Fatherhood Program and its representatives, affiliates, and partners the right and permission to photograph and/or record me during participation in program activities. I understand that these photos and videos may be used for promotional, educational, or informational purposes in print, digital, or broadcast formats, including but not limited to websites, social media, newsletters, brochures, and reports.I waive any right to inspect or approve the final products or any use to which the materials may be applied. I understand that I will not receive any compensation for the use of these images or recordings.
Please indicate your acceptance
I agree to the photo & video release waiver.
I do not agree to the photo & video release waiver. (Photos or videos of you will not be utilized or released)
Submit
Should be Empty: