OCF_OLD VERSION DO NOT USE! 2013 Intake Evaluation Form OCF Intake Form Question Title * 1. Today's date: What is today's date? Date Question Title * 2. Participant ID Question Title * 3. Agency Agency ID Agency ID 1- AFC 2- CCC (FF) 3- FD 4- TH 5- ULM 6- WSOS Agency ID Agency ID menu Question Title * 4. Agency Staff Member (First and Last Name) Question Title * 5. What county are you from? INSTRUCTIONS: When answering questions please be as honest and accurate as you can. This program is here to meet your needs and help you grow to become the best father possible to your child/ren. Question Title * 6. What do you need help with? (Check all that apply) Having a better relationship with my child/ren Having a better relationship with mother or legal guardian of my child/ren Expecting my first child Education Parenting Education Employment Drug or alcohol abuse/ addiction Child support- Seeking Modification Child support- Arrears (Overdue payments) Child support- Multiple Orders Getting to spend time with my child/ren/ Visitation Issues Seeking custody Establishing paternity Suspended drivers license due to child support arrears Domestic violence Legal advice/information/referral Felony Conviction Other (please specify) Question Title * 7. What is your race/ethnicity? (Please choose the ONE that best describes what you consider yourself to be) Native American or Alaskan Native Asian Black/African American (Non Hispanic) African National/Caribbean Islander Hispanic or Latino Middle Eastern Native Hawaiian/Pacific Islander Multi-racial White/Caucasian (Non Hispanic/European American) Other (please specify) Question Title * 8. What is your marital status? Married Single Divorced Separated Living with Mother of Child/ren Question Title * 9. What is your age? 13 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 and over Question Title * 10. What is your educational level? No high school degree High school degree or GED Some college Associate’s degree or trade/vocational school Bachelor’s degree Higher than bachelor’s degree Other (please specify) Question Title * 11. How many children do you have? Expecting 1 2 3 4 5 6 7 8 9 10 11 12+ Question Title * 12. How many, if any, of these children do you live with? None 1 2 3 4 5 6 7 8 9 10 11 12+ Question Title * 13. Are you a father to children under the age of 18? Yes No Next