Intake Form
Thank you for your interest in working with Parenting Plus! We are so glad you're here.

Please fill in as many questions below as you're able and then hit submit.
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First Name
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Last Name
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Your Date of Birth (Month-Day-Year)
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MM
/
DD
/
YYYY
Your Primary Language
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Your Best Mailing Address (street )
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What is your zip code?
*
Your Best Phone Number
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Your email address
What is your ethnicity?
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What is your annual household income (a good guess)?
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Are you a US Citizen (our services are open to all)
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PARENTING QUESTIONS
Are you currently pregnant?
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If currently pregnant, how far along/due date (if known)?
Are you currently parenting at least one child?
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If you're a current parent, please list the NAME, age,  gender, and birth date of each child in your care:
DIAPER BANK: what size of diapers do you currently need, if any?
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Required
Do you have an open CPS Case?
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If you have an open CPS Case, do you have a signed disclosure form?
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Are you court mandated for counseling or parenting classes? *
If mandated, please list your deadline for completion:
Which of these areas are you looking for help? Check as many as apply.
*
Required
Please tell us more about your family's situation and what needs we may be able to help you fill.
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Thank you for your time!
Completing this form will help you get on board as a Parenting Plus client. If you have not heard from us within one week, please call or email us at parentingplus.net.
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