PWG Intake Form & Confidential Questionnaire

Today's Date *
Today's Date
Name *
Name
Address *
Address
Daytime Phone *
Daytime Phone
Evening Phone *
Evening Phone
Do you have a case manager? *
Case Manager's Phone Number
Case Manager's Phone Number
Part A: Demographic Information
2. Are you a Domestic Violence Survivor? *
3. Marital Status *
4. Children under 18 *
5. Are you a single parent? *
6. Education Status *
7. Are you a Veteran of the U.S. Armed Forces? *
8. Ethnicity (check all that apply) *
9. In which Dress For Success® Honolulu program(s) have you participated in before joining PWG (check all that apply)? *
Part B: Participant/Program Fit
10. Are you currently employed? *
(Participants MUST be employed to participate in this program)
11. Are you a Federal Employee? *
12. Is your current position *
13. What percentage of desired hours are you currently working? *
14. Does your position provide the following benefits (check all that apply)? *
Part C: Barriers to Participation
15. This programs meets on a monthly basis for up to two hours in the evening. Are you able to commit this time to the PWG program? *
16. Do you foresee any of the following issues interfering with attending PWG meetings (check all that apply)? *
Part D. Financial
20. Housing *
21. Transportation *
22. Business Ownership *
24. Employment Challenges (check all that apply) *
Employer Address *
Employer Address
Employer Phone *
Employer Phone