Intake Name* First Last Phone*Email* Date* MM slash DD slash YYYY Best way to contact you*PhoneEmailReferral Source: QUESTIONS ABOUT YOU1. Do you receive food assistance (SNAP)?* Yes No If yes, are you classified as ABAWD?* Yes No 2. Do you need help obtaining social services to include Medicaid, TANF, SNAP?* Yes No 3. Are you employed?* Yes No If yes, what is your hourly wage?*If no, would you like help seeking employment?* Yes No 4. Do you pay child support?* Yes No If yes, what is your monthly child support amount?*5. Are you currently experiencing domestic violence?* Yes No Decline If yes, are you in need of immediate domestic violence services?* 6. Are you in need of mental health services?* Yes No 7. Are you currently accessing any mental health services?* Yes No If yes, what mental health services are you accessing?*8. Are you in need of any substance abuse services?* Yes No 9. Are you currently accessing any substance abuse services?* Yes No If yes, what substance abuse services are you accessing?*10. Is any child in your household receiving any supportive services, i.e. counseling, IEP?* Yes No If yes, what supportive services is your child accessing?*11. Are there any unmet needs or behaviors your children have that Gulf Coast Family Center can assist you with?* Yes No Decline If yes, what do you think would be helpful to meet your child's needs?*12. Are there any other concerns you may have for a child in your household?*SERVICES & REFERRALS OFFEREDInstructions: Please select any area you would like additional information or assistance in.Parenting Increased Engagement with your child(ren) Parent workshop(s) Child Development/Milestones Child Support Visitation with your child(ren) Parent Mentoring/Coaching Medical Care Child Care Age-Appropriate Discipline Relationships Monitored Exchanges Improved Communication Skills Understanding PFA/Restraining Orders Defining Toxic Relationships Compromising and Negotiating Domestic Violence Services Co-Parenting Managing Stress Anger Management Employment Obtain GED/Diploma Develop/Update Resume English as a Second Language Job Search Computer Skills Enroll in School Obtain Social Services Job Interview Workshop(s) Reliable Transportation Life Skills Medical Insurance Find Mental Health Services Find Substance Abuse Services Identify a Support System Identifying Self-Care Identifying Positive Relationships Learn Healthy Communication Addressing Legal Concerns Safe Housing Strengths – List three family strengthsStrength #1*Strength #2*Strength #3*GoalsWhat are three goals you have for yourself?Goal #1*Goal #2*Goal #3*What are three things you hope to learn in this parenting program?Hope #1*Hope #2*Hope #3*PERMISSION FOR RELEASE OF INFORMATIONConsent* I agree to the privacy policy.Our ability to offer this class to you at no charge is due to a grant from Children’s Trust Fund. Part of our grant requirements are to collect child support payment data. This data is shared only with Children’s Trust Fund. The Family Center does not release this information to any other organization. Child Support requires that The Family Center provide a release of information to obtain the information needed for the grant. I have been informed of my rights concerning the release of confidential information and I give my permission for The Family Center to obtain child support information to include but not limited to amount and payment history from DHR/ Child Support Enforcement. This release of information shall expire in 12 months or upon case closure, whichever occurs sooner:HiddenExpiration Date Type your name here* Signature* Reset signature Signature locked. Reset to sign again Date* Reset signature Signature locked. Reset to sign again HiddenCenter Staff Witness HiddenDate CAPTCHA Δ
