Connecting Fathers, Connecting Families Pre-Screening Form

Connecting Fathers, Connecting Families

Pre-screening Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you a Father or Father figure?*

YesNo
**This is includes Biological, Custodial, Legal, Adoptive, Foster, Stepfather, Grandfather, Non-relative Male, or Male family member serving in the role of Father to a dependent child or children
Best way to contact you.*

Phone CallText MessageEmail
Select the Florida County that you live in.*

Osceola CountyLake CountySumter CountyVolusia CountyPutnam CountyNone of the above
Are you currently receiving any of the following?*

TANF (Temporary Assistance for Needy Families)SNAP (Food Assistance/EBT)Re-employment AssistanceNone of the above
Have you been incarcerated in the last 5 years or are currently involved with the justice system?*

YesNo
Do you have a child support order or owe back child support?*

YesNo
Are you currently participating in any of the following programs?*

Batterers Intervention Program (BIP)Parenting ClassesFamily Court or DCF Involvement (Chapter 39)None of the above
Would you like support with any of the following?*

Finding a jobManaging child supportReentry or justice system supportAccessing healthcareParenting/Co-parenting helpChild development understanding
Should be Empty:

Connecting Fathers, Connecting Families