Alabama Parenthood Initiative Client Intake/Needs Assessment



Are you Hispanic or Latino?

What is your race? (Choose one or more)

Marital Status

Employment Status


Children Information:

Client Needs:

Do you need help prepare for a job?

Are you currently receiving unemployment?

Do you need additional education?

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 improve your parenting skills?

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:

Responsible Parenting/Healthy Relationship/Economic Stability Needs:

Check all needs that apply to you:

Case Management/Supportive Service Needs:

Check all needs that apply to you: