Fatherhood Development Workshop / Strong Fathers Class Registration

Todays Date

MonthDayYear
Date
Strong Fathers Intake Form
Full Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Social Security Number*
Date of Birth*

MonthDayYear
Date
Are you currently on

ProbationParoleWork ReleaseHouse ArrestCommunity ServiceIncarcerated
Phone Number*

Area CodePhone Number
If we cannot reach you, who can we contact?
Are you registered for Selective Service*

YesNo
Do you have a disability*

YesNo
Please enter you emergency contact name, phone number and relationship
Are you a Veteran

YesNo
Employment*
Employer Name
Hourly Rate ($/hr)
Number of Hours per Week
Number of Days Employed (ex. 30, 60, 90, etc.)
If employed, list 1) Employer, 2) Hourly Rate 3) Number of Hours per week worked 4) Number of days employed
Are you looking for a job
Please estimate your annual Income*
Number of people in household that you are responsible for (i.e. Children, partner, spouse)*
Gender*

MaleFemale
Race*
Ethnicity*

HispanicNon Hispanic
Marital Status*
Are you a parent?*

YesNo
Are you a Father or Caregiver*

YesNo
Are you an expectant Father*

YesNo
Where you ever in Foster Care as a child?*
Due Date

MonthDayYear
Date
Pregnant Mother's Name

First NameLast Name
Are you a US Citizen*

YesNo
How many Children do you have?*
How many of your children are under 18

Children's Information (Please list DOB as MM-DD-YYYY)

	Childs Name	Age	Date of Birth	Gender	Paternity Established
Child 1
Child 2
Child 3
Child 4

Housing: You are currently?*

Renting an apt/homeLiving with Family/FriendsBuying a homeHomeless
Are you receiving any of the following*

Child SupportChild Care AssistanceFood StampsMedical AssistanceLow Income Subsidized HousingSSI/SSDISalary/WagesUnemployment InsuranceTANFNONE
Have you ever been Arrested?*

YesNo
Have you ever been In Jail?*

YesNo
Have you ever been In DOC/Prison?*

YesNo
What type of convictions do you have*
Where are you incarcerated*

PendletonMiamiMichigan CityPlainfield
Please enter the date of release
What is your release date?*
Would you like assistance looking for a job>

YesNo
Are you Head of Household?*

YesNO
How engaged are you with your children?*

Not at allVery LittleSomewhatVery Much
Annual Household Income*
Education*
Last Grade Completed*
List Special Skills and Certifications
Do you feel safe in your current relationship?*
Is there a partner from a previous relationship who is making you feel unsafe now?
I would like more information on
After Clicking submit you will be directed to Indiana Career Explorer. Create an account and complete the Career Assessment*

CLICK HERE STATING THAT YOU UNDERSTANDCLICK HERE FOR MORE ASSISTANCE AND SOMEONE WILL CALL YOU TO HELP
We will call you to schedule a time for you to come in and meet with a specialist*

CLICK HERE STATING YOU UNDERSTANDCLICK HERE IF YOU DO NOT UNDERSTAND AND SOMONE WILL CALL YOU TO HELP
Can you pass a drug test

YesNo
Are you experiencing any of the following

DentalSeizuresVisionHearingMigraine HeadachesHeart ProblemsDiabeticDepressionPTSDADHDDyslexiaBi-Polar DisorderSchizophrenia
Are you currently receiving Mental Health Treatment or Counseling?*

YesNo
Have you received Mental Health Treatment or Counseling in the past?*

YesNo
Are you currently prescribed any medication*

YesNo
Are you currently taking any prescribed medication*

YesNo
Up to what age was your father present in the home when you were growing up?
When you were growing up, how involved was your father with you?

Not at allVery LittleSomewhatVery MuchNot Applicable
How would you describe the relationship with your father now

PoorFairGoodVery GoodDeceasedNot Applicable
How engaged are you with your children*
Do you have an open DCS Case?

YesNo
Have you been vaccinated for Covid 19

YesNo
COVID Impact (Last 6 Months)*

Laid Off/DisplacedStopped Seeking EmploymentUnable to Find EmploymentNot Affected
ARE YOU VACCINATED FOR COVID 19*

YesNo
RELEASE OF INFORMATION

I understand that my participation in Fathers and Families Center (affiliated with Eskenazi Health) programs, services and activities is voluntary. I certify that all information is accurate and complete. Any information learned about me for this interview or during my involvement in this program may be shared with other FFC staff members and others as appropriate and according to HIPAA guidelines. Further, I understand that information or images/photos about me can be used to promote Fathers and Families Center as long as I am not identified by full name or social security number. Please sign and date below
Please sign and date below
*

Clear
After you click submit COMPLETE THE NEXT FORM COMPLETLY to complete the sign up process.

Option 1Option 2Option 3
Where did you hear About Fathers and Families Center*
Friend/Family Member's Name

First NameLast Name
Please upload a copy of your ID to complete enrollment

Browse Files

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Have you completed Orientation*

YesNoAlumni
If you have not completed Orientation, please contact Ms. Rhonda at 317-921-5935 to enroll today.
Class Number*
What class are you enrolling in?
Should be Empty:

Strong Fathers Intake Form

RELEASE OF INFORMATION