Intake for classes

Please complete the questionnaire below and reach out to us at www.parentingplace.net/contact if you have any questions. Thank you!

Services are available to all persons, regardless of race, ethnicity, gender, age, disability, sexual orientation, or religion.

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* 1. What is today's date?

Date of Survey Taken

Date

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* 2. What is your contact information?

Name *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

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* 3. Who is your emergency contact?

Name

Relationship

Email Address

Phone Number

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* 4. How did your family hear about our program?

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* 5. Who referred you to us?

Background Information

Your answers to the following questions will provide background information that will help us refer you to relevant resources. You do not have to answer these questions to receive services from the Parenting Place. The information you give is confidential and will not be shared with other agencies without your permission.

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* 6. Please check all of the community services you are currently involved with?

Child Development Center

Child Care Resources

SSI

CASA

Early Head Start

Head Start

Health Dept.

Healthy MT Kids

LIEAP (energy assistance)

Job Service

Pre-Release

Probation/Parole

SNAP

TANF

WIC

Low Income Housing Assistance

Mental Health Services

Disability Services

Please Describe: Mental Health Services or Disability Services

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* 7. Do any of your children have a disability?

Yes

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* 8. Do you have any disabilities?

Physical

Developmental

Mental Health

None of the above

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* 9. Do you currently have an open case with The Department of Child and Family Services?

Yes

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* 10. Have you been homeless in the last 5 years?

Yes

Intake for classes

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* 1. What is today's date?

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* 2. What is your contact information?

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* 3. Who is your emergency contact?

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* 4. How did your family hear about our program?

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* 5. Who referred you to us?

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* 6. Please check all of the community services you are currently involved with?

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* 7. Do any of your children have a disability?

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* 8. Do you have any disabilities?

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* 9. Do you currently have an open case with The Department of Child and Family Services?

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* 10. Have you been homeless in the last 5 years?

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* 11. What are your main concerns right now?

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* 12. Please share a few things that are going well in your life right now:

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* 13. My favorite things about being a parent are:

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* 14. Please type your first and last name here along with the date as your Electronic Signature.
Example: Jane Doe 7/25/2022

Intake for classes

Question Title

* 1. What is today's date?

Question Title

* 2. What is your contact information?

Question Title

* 3. Who is your emergency contact?

Question Title

* 4. How did your family hear about our program?

Question Title

* 5. Who referred you to us?

Question Title

* 6. Please check all of the community services you are currently involved with?

Question Title

* 7. Do any of your children have a disability?

Question Title

* 8. Do you have any disabilities?

Question Title

* 9. Do you currently have an open case with The Department of Child and Family Services?

Question Title

* 10. Have you been homeless in the last 5 years?

Question Title

* 11. What are your main concerns right now?

Question Title

* 12. Please share a few things that are going well in your life right now:

Question Title

* 13. My favorite things about being a parent are:

Question Title

* 14. Please type your first and last name here along with the date as your Electronic Signature. Example: Jane Doe 7/25/2022

* 14. Please type your first and last name here along with the date as your Electronic Signature.
Example: Jane Doe 7/25/2022