Fatherhood EFFECT Application

First Name

Last Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Preferred Language

Street Address

City

County of Residence

Role

Child/Youth Name or Initials

Child/Youth Date of Birth or Expected Due Date

Date

Relationship to this Child/Youth

Is the child/youth between 0 and 17 years old, or are you an expectant father?

List any other children or youth living in the home who may be impacted by this program, in addition to the child/youth named on the previous page. Add a row for each child, or leave blank if none.

Other children in the home

Services are voluntary, free of charge, and provided regardless of economic status.

Do you reside in, or primarily receive services in, Montgomery, Liberty, San Jacinto, or Tarrant County?

I understand that participation in Fatherhood EFFECT is voluntary and free of charge, and is provided without regard to my economic status, race, gender, age, disability, or religion. I understand that MET Inc. will keep my information confidential to the extent permitted by law, and that information may be shared with the Texas Health and Human Services Commission (HHSC) for program reporting purposes. I understand I may withdraw from the program at any time without penalty. I certify that the information provided on this application is true and accurate to the best of my knowledge.

Do you or your household currently have a confirmed or open case with Child Protective Services (CPS) or Child Protective Investigations (CPI)?

Are you currently incarcerated?

HHSC requires that enrolled families exhibit at least two of the characteristics below. Check every one that applies to you, your child, or your household.

Fatherhood EFFECT Application

Applicant Information

Connection to a Child or Youth

Other Children in the Home

Eligibility Screening

Consent & Signature

Priority Characteristics