Fatherhood Program Intake and Needs Assessment

Men and Fatherhood Engagement Registration and Questionnaire

Please fill out this form to register and help us understand your needs and interests for the upcoming men and fatherhood engagement event hosted by our Ministry.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Preferred Name
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Marital/Relationship Status*
Race/Ethnicity*
Preferred Language*
Number of Children*
Ages of Children (please list)*
Child Custody Status or Living Arrangements*
Relationship to Children*
Current Living Situation*
Food Security: Do you have regular access to groceries or meals?*

YesNo
Do you have reliable transportation?*

YesNo
Current Employment Status*
Occupation and Employer (if applicable)
Highest Education Level Completed*
Job Training or Interests
Physical Health Status*
Mental Health Status*
Do you currently have health insurance coverage?*

YesNo
Substance Use Concerns (optional)

AlcoholDrugsNoneOther
Are there active child support orders or legal issues related to child support?*

YesNo
Criminal Justice Involvement (optional)

YesNo
Key Social Supports (family, friends, organizations)
Involvement with Community Resources

ChurchesSupport GroupsOther
Parenting Role and Involvement Level*
Services Interested In*

EducationMentoringAdvocacyFather-Child ActivitiesCustody SupportMen's Mental HealthOther
Challenges or Interests in Parenting Topics
Short-term and Long-term Goals
Preferred Communication Method*
How did you hear about the program?
Relationship Type with the Mother(s) of Your Children*
What was the relationship with your dad like?
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Website
Previous Programs or Support Services Received

Men and Fatherhood Engagement Registration and Questionnaire