Partners in Parenting Eligibility ScreeningClient/Family Information*Individuals must be 19 years of age or under, a U.S. citizen, not in their home of origin, and meet income requirements to be eligible for this service.Name *(first and last)Date of Birth *(m/d/yyyy)Age *Last Four Digits of Your Social Security Number *Parent Name(s) *Phone Number *Email Address *Home Address *Are you a U.S. citizen? *YesNoHow did you hear about our program? *Presenting ProblemWhat specific CEDARS program or service are you requesting? *(shelter, etc.)What are the presenting circumstances?/What brought you here? *(Lack of resources, current behavioral or mental health issues, etc.)Have you ever received services from CEDARS before? *YesNoAre you available to meet for at least two hours weekly, Monday through Friday? *YesNoN/APregnant/ParentingAre you pregnant or parenting? *YesNoWhat stage of pregnancy are you in?If you are not pregnant, but are parenting, please write N/A.What are the names, ages, and sexes of your children?If the you are pregnant, but not currently parenting, please write N/A.Living ArrangementYou must no longer live in your home of origin, or with your family of origin, to be eligible for this service.Where do you currently reside? *Who do you currently live with? *IncomeAre you currently working? *YesNoWhere do you work?Are you working part-time or full-time?Part-timeFull-timeWhat is your wage?Are you receiving WIC services and/or SNAP benefits? *YesNoDo you receive any other source of income? *YesNoWhat is that additional source of income?Strengths/StrugglesWhat resources do you rely on? Who do you consider to be your support system (formal and informal)? *Do you have any special concerns or needs? *YesNoWhat are your special concerns or needs?Do you struggle with past experiences of abuse or neglect (physical or sexual)? *YesNoDo you have any current or historical issues with running away or threatening to run away? *YesNoDo you have any current safety issues? *YesNoWhat are your current safety issues?EducationWhat is your current educational status? *Currently Attending High SchoolReceived High School DiplomaCurrently Working Towards a GEDReceived GEDDropped Out of High SchoolOther...What school do you attend?Mental and Behavioral HealthAre you currently, or have you ever, struggled with thoughts of hurting yourself or others? *YesNoDo you have any other behavioral health concerns or issues that have not been discussed yet? *YesNoWhat are your additional behavioral health concerns or issues?Are you currently in therapy? *YesNoAre you interested in individual or family therapy with our clinician?YesNoSubstance UseDo you have current or historical use of drugs or alcohol? *YesNoLegalLegal Guardian(s) *Law Violations/Warrants *If you don't have any law violations or warrants, please write N/A.Submit
