Assistance

I Need Assistance!

If you are in need of assistance please fill out the the following form. Once your request has been received someone will contact you shortly.

Eligibility Requirements:

I’m between the ages of 13 and 23 years old.

I am parenting my child.

I am a US Citizen or documented resident.

Today’s Date *

Name *

E-mail Address: *

Have you ever applied for our Program? *

Yes
No

How did you hear about Help A Sister Out?

Friend
Human Services
Television
Radio
Social Media (Facebook, Instagram, etc)
Internet Search (Google, etc)
School
Church
Teacher
Medical Office
Other

Date of Birth * / /

Age at Intake

Ethnicity *

American Indian/Alaskan Native
Asian
African American/Black
Caucasian/White
Hispanic
Native Hawaiian or Pacific Islander
Other

Citizenship *

US Citizen
Non-citizen
Lawful Status (i.e, DACA)
Applied for Lawful Status

Physical Address *

Phone Number *

Emergency Contact

Emergency Contact Phone Number

How many children do you have?

Are you pregnant? *

Yes
No

Are you on birth control? *

Yes
No

How many nights do you spend with your child per week? *

My child is with me all the time
6 nights a week
5 nights a week
4 nights a week
3 nights a week
2 nights a week
1 night a week
I do not Spend any nights with my child

Child Name *

Child Gender *

Male
Female

Child Date of Birth * / /

Child’s Ethnicity *

American Indian/Alaskan Native
Asian
African American/Black
Caucasian/White
Hispanic
Native Hawaiian or Pacific Islander
Other

Does your child have any of the following health conditions? *

Allergies
Epilepsy
Speech Issues
Physical Development Issues
Hearing Issues
Vision Issues
Other

Language(s) spoken in the home

English
Spanish
English & Spanish
Other

Name of Father *

Father’s Age

Father’s Phone Number

Highest grade of school completed? *

Do you have college or vocational training? *

Yes
No

Are you currently working? *

Yes
No

Do you have your GED or High School Diploma? *

Yes
No

Are you currently attending school? *

Yes
No

What is your relationship status? *

Single
Dating
Engaged
Legally Married
Separated
Divorced/Widowed

Who do you live with? *

Alone
Spouse
Domestic Partner/Boyfriend
Extended Multi-family
Both Parents
Single Parent
Grandparent
Foster Home
Hotel/Motel
Car
Transitional Housing
Friend(s)
Other

In the past 6 months, have you had problems getting along with:

Mother
Father
Boyfriend
Girlfriend
Fiancé
Spouse
Brother
Sister
Children
Ex
No one at all

Have any of these people abused you emotionally, physically or sexually? *

Yes
No

Your Father’s Name

Your Mother’s Name

Is there anyone that wants to hurt you? *

Yes
No

Do you have a restraining order against anyone? *

Yes
No

Do you believe in God?

Yes
No

Do you have a Georgia Drivers License *

Yes
No

What do you do for transportation? *

Own a car
Bus/Train
Lyft/Uber
Other

Do you currently smoke? *

Yes
No

In the past 3 months, have you abused any of the following? Please select all that apply *

Alcohol
Cocaine
Meth
Prescription Drugs
None of the Above
Other

Have you ever been treated for an alcohol or drug problem? *

Yes
No

Do you have a physical disability? *

Yes
No

Does anyone in your family suffer from the following? *

Nervous Breakdown
Depression
Strange/Peculiar Behavior
Suicide Attempts
Anxiety Disorder
Memory Loss
Violent Behavior
Panic Attacks
Other

In the last 3 months have you experienced: *

Anxiety or Tension
Suicide Attempts
Wanting to harm yourself
Trouble controlling violent behavior
Trouble understanding
Concentrating or remembering things
Depression
Thoughts of suicide
Panic attacks
None of the above

Have you been treated for emotional or psychological problems? *

Yes
No

Have you ever been charged with: *

Shoplifting
Forgery
Failure to appear
Vandalism
Child Neglect
DUI/DWI
Theft
Child Abuse
None of the above
Other

Are you currently on: *

Probation
Parole
Court Supervision
None of the above

Do you currently have parenting orders? *

Yes
No

Do you have charges pending? *

Yes
No

Have you ever been involved in a gang or participated in gang activity? *

Yes
No

Is there a warrant out for your arrest? *

Yes
No

Have you had any previous arrests? *

Yes
No

Have you ever been involved with social services? *

Yes
No

Have you ever been or will you be required to register as a sex offender? *

Yes
No

What are you interested in? Please select all that apply. *

GED
Residential Program
College/Job Help
Parenting Classes
Healthy Relationship Classes
Legal Assistance (i.e. protection orders, parenting orders)
Budgeting/Finance Classes
Supportive Adult Relationships
Meeting other Teen moms through activities
Other

If you could study anything in college, what would it be and why? *

What is your dream job and why? *

Are there any other things that you would like our help with? *

If you have more than one child, list their names and ages here: *

I hereby certify that the information I have given is complete and accurate to the best of my knowledge. *

Signature *

* Required