Community

Alabama Parenthood Initiative Client Intake/Needs Assessment

 
 
 
 
 
 
 

Gender:


Are you Hispanic or Latino?


What is your race? (Choose one or more)





Marital Status






Employment Status






Income:






Children Information:

Client Needs:

Do you need help finding a job?


Do you need help finding a better paying job?


Are you currently receiving unemployment?


Do you need additional education or skills training?


Do you have transportation?


Do you have stable housing?


Have you applied for disability or have a pending case?


Is there any reason you cannot go to work?


Is there any reason you cannot attend/complete training?


Do you want to be a better parent to your children?


Do you want to see your children more often?


Does your relationship with the other parent need improvement?


Have you ever been convicted of a crime (other than a ticket)?


Are you currently on Probation?


Do you have any pending charges/court cases?


Economic Stability Needs:

Please check all that apply:







Please list any other Economic Stability Needs not listed above that apply to you.

Responsible Parenting/Healthy Marriage Needs:

Check all needs that apply to you:






Case Management/Supportive Service Needs:

Check all needs that apply to you:






Please list any Responsible Parenting/Health Marriage Needs you may have not listed above: