Community Intake Form
First Name
Last Name
Email Address
Gender
Female
Male
Prefer not to answer
Marital Status
Married
Single
Divorced
Widowed
Race
African American
White
Hispanic
Asian
Other
Ethnicity
Hispanic
Non-Hispanic
Zip Code
Number of kids
Age of kids
How did you hear about this event?
Please briefly share how your family has been impacted by incarceration?
On a scale of 1 to 10, how would you rate the connection with your children?
0-1: Little to no connection
2-3: Irregular contact; few times per year
4-5: Some weekends/holiday
6-7: Regular weekends/holiday, plus school involvement and contact outside of custodial parent.
8-9: Live in same home but other parent handles most daily activities.
10: Live in the same home; hands on with all daily activity.
Are you in need of any resources/services? If so, please explain.
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