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2. 
3. 
   Department of Human Services
   Fatherhood Development Group
   Referral Form
5. Participant Information
7. First Name
8. Last Name
10. Address 1
12. Address 2
14. City
15. State
16. Zip Code
18. Home Phone #
19. Cell Phone #
21. Emergency Contact
23. First Name
24. Last Name
26. Phone Number
27. Cell Phone Number
29. Race
31.  

    1. African American

    1. Caucasian

    1. Hispanic

    1. Asian
33. Other:
35. Age of Participant
37.  

    1. Under 18
    2. 18-29

    1. 30-39
    2. 40-49

    1. 50-59

    1. 60 and up
39. Children
41. Number of Children
42. Ages of child/children
44. Is there more than one mother involved?

    1. Yes
    2. No
45. If yes, how many?
47. Frequency of contact with children

    1. Daily
    2. Weekly

    1. Bi-weekly
    2. Monthly

    1. Sporadic

    1. Never
49. Would you like assistance with developing a visitation plan with your child/ren?

    1. Yes

    1. No

    1. Unknown
51. If yes, list name and contact number for the custodial parent:
53. Custodial Parent Last Name
54. Custodial Parent Last Name
56. Home Phone Number
57. Cell Phone Number
59. Is there a court order in place that prohibits you from contacting the custodial parent and/or your children?

    1. Yes

    1. No
60. Would you like assistance with employment resources?

    1. Yes

    1. No
64. If you could have a resource provided to enjoy time with your child or children, which of these might you prefer? Please check top 3 choices.

    1. Bus Passes
    2. Clothing Gift Card

    1. Tide Game Tickets
    2. School Supplies

    1. Food Gift Card
    2. Zoo passes

    1. Movie passes
66. Other:
70. Barrier: Notate if obvious from conversation. No need to discuss in detail.

    1. Homeless
    2. Limited education: highest grade or GED
    3. Limited job skills
    4. Parenting skills needed
    5. Ex-offender: list any felony convictions:

    1. Substance abuse issues
    2. Visitation issues
    3. Underemployment
    4. Unemployment
72. Ex-offender: list any felony convictions:
76. Referral Information
78. Referral Person First Name
79. Referral Person Last Name
81. Referring Agency
83. Referral Contact Number
84. Referral Date:
    Referral Date:

    Referral Date:
86. How did you initially hear about the Fatherhood Development Group?

    1. Flyer
    2. Email

    1. Website
    2. Caseworker

    1. Court Order
    2. Presentation

    1. Word-of-mouth
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit Submit and Print

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