Dads Against Crime Intake Form Name * First Name Last Name Email * Date of Birth * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Emergency Contact- Name and Phone Number * What brings you in today? * Therapy Mentorship Employment Services Felony Expungement How did you hear about us? * Facebook Google Yelp Website Other Race/Ethnicity * Black or African American Caucasian or White American Hispanic or Latino Asian Mixed/Multiple Ethnicities Other Do you do any of the following? * Marijuana Cocaine Heroin Methamphetamine Prescription Drugs ( Not prescribed to you) Alcohol None Are you a felon? * Yes No Do you have transportation? * Yes No Are you homeless? * Yes No Do you have mental health concerns? * * Yes No Are you a veteran? * Yes No Thank you!
