Fatherhood Programs Intake Participant ID* Instructions: Please mark your answer to the following questions about yourself. Your answers will be kept confidential. If you have any questions, please notify the program staff.1. What is your sex?* Male Female 2. What is your age in years?* 3. What is your current relationship status?* Single Committed Relationship (Not Married) Married 4. Have you ever been separated?* Yes No 5. Have you ever been divorced?* Yes No 6. Have you ever been widowed?* Yes No 7. Are you of Hispanic, Latino or Spanish ethnicity?* Yes No 8. What is your race?* African American / Black American Indian or Alaska Native Asian American / Asian Bi-racial European American / White Native Hawaiian / Pacific Islander Other – Please List Below Other 9. What is the highest level of education you have attained?* Did not finish high school High School Diploma / GED Trade School / Technical Certificate Associate’s Degree Bachelor’s Degree Master’s Degree / Advanced Degree 10. What is your current employment / job status?* Full Time Employment (35 or more hours a week) Part Time Employment (1-34 hours a week) Employed, but number of hours change from week to week Temporary, occasional, or seasonal employment or odd jobs for pay Not currently employed 11. If you are NOT currently employed, are you: Actively looking for work Retired Disabled NOT actively looking for work 12. How much do you earn from wages each month?* Nothing, I am unemployed $100 – $799 $800 – $1,599 $1,600 – $2,499 $2,500 – $3,299 $3,300 – $4,099 $4,100 – $4,999 $5,000 or more 13. If you are employed, how long have you held your current job? (Skip if not employed) Less than 1 month 1 – 3 months 3 – 6 months 6 – 12 months 1 year or more 14. Do you receive any of the following benefits?* SNAP (EBT / Food Stamps) TANF (Temporary Assistance for Needy Families) I receive BOTH forms of public assistance (SNAP & TANF) I do not receive either form of public assistance 15. Are you currently incarcerated (in jail)?* Yes No 16. Were you referred by the court to attend this class?* Yes No 17. How much total are you court ordered to pay in monthly child support?*18. How much were you able to pay last month?*19. If you were NOT able to pay the full amount, why?Below is a list of personal challenges that some people experience. Think about the challenges that you have had in the past month. Please mark one per question: (if you have not experienced this challenge in the past month), (yes, a little), (yes, somewhat), or (yes, a great deal).Have you had a problem with…1. Unemployment* No, not at all Yes, a little Yes, somewhat Yes, a great deal 2. Not having a place to live* No, not at all Yes, a little Yes, somewhat Yes, a great deal 3. Drug / Alcohol Use* No, not at all Yes, a little Yes, somewhat Yes, a great deal 4. Physical health problems* No, not at all Yes, a little Yes, somewhat Yes, a great deal 5. Living too far from your child(ren)* No, not at all Yes, a little Yes, somewhat Yes, a great deal 6. Keeping a job when you have one* No, not at all Yes, a little Yes, somewhat Yes, a great deal 7. Not knowing how to deal with family or civil court* No, not at all Yes, a little Yes, somewhat Yes, a great deal 8. Transportation issues* No, not at all Yes, a little Yes, somewhat Yes, a great deal 9. Not having health insurance for yourself* No, not at all Yes, a little Yes, somewhat Yes, a great deal 10. Not having health insurance for your child(ren)* No, not at all Yes, a little Yes, somewhat Yes, a great deal Please rate how often each statement has been true for you in the past 2 weeks. Please mark one per question: (None / Little of the time), (Some of the time), (Most of the time), or (All of the time).How often has each statement been true?1. I don't feel as powerful* None / Little of the time Some of the time Most of the time All of the time 2. When I am with people, I don't feel part of things* None / Little of the time Some of the time Most of the time All of the time 3. I've had a short fuse* None / Little of the time Some of the time Most of the time All of the time 4. I don't get sad, I get mad* None / Little of the time Some of the time Most of the time All of the time 1. How many children do you have? Mark all that apply.How many biological children?How many step-children?How many grandchildren?How many foster children?How many adopted children?2. How many of these children have special needs?Who lives in your home with you most or all of the time? Mark all that apply.How many biological children?How many step-children?How many grandchildren?How many foster children?How many adopted children?Your Boyfriend / GirlfriendYour Husband / WifeYour SisterYour BrotherYour FatherYour MotherYour StepfatherYour StepmotherAny other person who lives with you? CAPTCHA Δ
