Furthering Fathering Georgia
Client Intake Form
Personal Information
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
Age
Gender
*
Select gender
Male
Female
Race/Ethnicity
*
Select race/ethnicity
Hispanic
Black
White
Asian
American Indian or Alaska Native
Multi-racial
Native Hawaiian or Other Pacific Islander
Are you a parent?
Select
Yes
No
Number of Children
Contact Information
Email
*
Phone
*
Street Address
*
City
*
State
*
ZIP Code
*
How Did You Hear About Us?
How did you hear about us?
Referred By
Reasons for Connecting
Select all that apply
Legitimation
Employment
Child Support Navigation
Marriage Coaching
Life Coaching
Brotherhood
Fellowship
Meet Ups
Program (Fostering Family Leaders, Connect Barbershop, Reentry, H.E.A.R.T., Legacy Circle)
Volunteer
Mentoring
None of the Above
Additional Information
Additional Comments
Submit Intake Form