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OCTF Parent Caregiver Intake Form
Please type NA for any questions that do not apply to you and your family
Date Application Completed: (MM/DD/YYYY)
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Who referred you to the Getting Ahead Program?
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Participant Information
First Name:
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Last Name:
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Date of Birth: (MM/DD/YYYY)
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Social Security Number:
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Address:
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City:
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Phone Number:
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Time in Residence: years/months
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What is your County of Residence?
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Email Address:
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Have you been involved in a Children Services child abuse and/or neglect case?
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Yes
No
Was there a substantiated CSB case?
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Yes
No, there were no findings and the case was closed.
Is this case still open?
Yes
No
Government Assistance Being Received
Are you currently receiving any of the following? (Select all that apply.)
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TANF/Ohio Works First Cash Assistance
Food Assistance
Medicaid
WIC
Earned Income Tax Credits
Head Start/Early Head Start Services
Child Care Subsidy
NA
Other, Please Specify
Other, Please Specify
Do you or your family have other needs, e.g. housing, food, clothing, mental health, etc.? Please specify.
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Participant Demographics
Age:
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Sex:
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Male
Female
Transgender
Do not identify as male/female/transgender
Other
Marital Status:
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Married
Partnered
Single
Divorced
Widowed
Separated
Are you a veteran of the U.S. Military?
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yes
no
If you are a Veteran, what Branch of the Military?
Race, Ethnicity:
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American Indian/Alaskan Native
Asian
African-American/Black
Caucasian/White
Native Hawaiian/Pacific Islander
Two or more races
Prefer Not to Answer
Other, Please specify
Other, Please specify
Are you Hispanic or Latino origin?
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Yes
No, not of Hispanic, Latino, or Spanish origin
Prefer not to answer
Education and Employment
Education:
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Elementary or Junior High School
Some High School
High School Diploma or GED
Trade/Vocational Training
Some College
2-Year College Degree (Associate's Degree)
4-Year College Degree (Bachelor's Degree)
Master's Degree
PhD or Other Advanced Degree
Are you currently enrolled in an education or training program?
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Yes
No
If yes, please describe:
What is your current employment status?
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Full-Time
Part-Time
Unemployed
Disabled
Volunteer
Are you currently seeking work?
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yes
no
Employer, if applicable
Number of Hours Weekly:
How long have you worked there?
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Do you have a physical, mental or developmental disability or delay?
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Yes
No
Health and Medical
Do you currently have heath concerns? Please explain:
Do you require reasonable accomodations? Please explain
What type of healthcare coverage do you have?
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Private (through employer)
Private (not through employer)
COBRA
Medicaid
Medicare
NA
Criminal History
Have you been convicted of a criminal offense other than a traffic violation?
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Yes
No
If yes,
Date and Nature of Offense
Misdemeanor Offense
Date and Nature of Offense
Felony Offense
Date and Nature of Offense