Family Education and Support Intake
About You
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Your Email Address
*
example@example.com
What is the best way to reach you?
*
By Phone
By Email
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Current Age
*
Gender
*
Race
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
About Your Children
Enter your Child(ren)'s Information below
*
Full Name
Current Age
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6
Child #7
Referral Information
How did you find out about the Family Education and Support Classes?
*
DCS / CPS
Probation
Attorney
Other
Please provide more information on your answer of "other"
What is your Caseworker/Attorney/Probation Officer’s Name?
*
First Name
Last Name
Caseworker/Attorney/Probation Officer’s Phone Number
Please enter a valid phone number.
Caseworker/Attorney/Probation Officer’s Email Address
example@example.com
What county does your worker serve?
*
Parenting & Support Information
What are your current methods of discipline?
*
What are some nurturing behaviors to use with your child?
*
What are some community resources you use?
*
Are you currently involved in any Community Organizations?
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Yes
No
Please provide information on the Community Organizations
Do you have other social supports such as family and friends?
*
Yes
No
Please provide information on your social supports
What brought you into the Family Education classes?
*
Please answer the following questions:
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Yes
No
Are you the custodial parent?
Are you ordered to pay child support?
Are you currently living with the other parent of the child?
Does your child/children reside in the home with you?
Do you feel isolated and frustrated by your current parenting situation?
What type of relationship do you have with the other parent (co-parent) of the child? For example, do you cooperate with one another? Is the co-parent active in the care of the child? Do you discus the discipline of the child? If not living with the other parent, do you disagree over child support?
*
What are two methods YOU use to deal with stress in your life?
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What are two methods YOU use to deal with anger?
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What are two ways you respond to your child’s misbehavior? (For example: do you yell, talk things over calmly, sigh, ignore behaviors, etc?)
*
How often do you visit your child/children?
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How often are you allowed to visit your children?
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Do you visit your child/children every time you are allowed to?
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Yes
No
Where do you meet to visit?
*
Does your visit with your children end on a positive note? (For example: did you and your child laugh/play together? Did you have problems when it was time to return the child to the other parent? Did you give your child a compliment and assure them the current situation was not their fault?
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Submit
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