Family Advocate Information Form

Please note: All fields are required. If you do not know the answer to the question or it does not pertain to the situation, enter N/A or unknown.

Demographics

Name(Required)

First Last

DOB(Required)

Marital Status(Required)

Race(Required)

Please list "other"(Required)

Language spoken in the home(Required)

Gender(Required)

Male

Female

Other

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone Number(Required)

Social Media

Emergency Contact Name

Emergency Contact Phone

Local Family

How did you hear about Better Together?(Required)

What goals would you like to accomplish over the next month?(Required)

What are your strengths?(Required)

What life skills would you like to improve on?(Required)

What are your current needs?(Required)

What is your communication Style?(Required)

(Example: Friendly and outgoing; Usually wait to be approached by someone new; Reserved until you get to know someone)

Are you currently employed?(Required)

Yes

Employer Name(Required)

Employer Phone Number(Required)

Work Schedule and Availability(Required)

What type of employment skills do you have?(Required)

Government Assistance (Select all that apply)(Required)

If other, please list(Required)

Do you have a valid Driver's License?(Required)

Yes

Transportation(Required)

Personal Vehicle

Public Transportation

Friend/ Family

Do you currently receive child support?(Required)

Yes

Do you currently receive housing assistance?(Required)

Yes

If yes, which program?(Required)

What Housing Programs have you applied for?(Required)

What Community Resources are you currently utilizing?(Required)

What Community Resources have you accessed in the past?(Required)