SECTION 2: Family Information

Are you currently a single parent?

Yes

How many children do you have?

Ages of Children

Do your children live with you full-time, part-time, or shared custody?

Full-time

Part-time

Shared custody

Other (explain)

Other Custodial Arrangements

SECTION 4: Support Needed

We provide different types of support. Please select what best describes the help you need. Don’t worry — we’ll discuss details on your call.

Which type of support do you need right now? (select all that apply)

Emergency Support – Immediate help for urgent situations like food, shelter, utilities, or safety concerns. Financial Su

Financial Support – Assistance with bills, childcare, transportation, or other ongoing financial needs.

Resources or Referrals – Guidance to other programs or services.

Other (please explain)

Please explain other support that you may need

“If EmpoweredPath Alliance (EPA) could help you with ONE thing immediately, what would it be?” (short answer)

SECTION 6: Safety & Stability

Do you feel safe where you currently live?

Yes

Prefer not to say

Is there anything happening at home that affects your ability to provide for your children?

SECTION 7: Document Verification Prep

To complete the intake process, please have proof of your need ready to show during your Parent Support Intake Call. This can include ID, income verification, or any documentation relevant to your request. You do not need to upload anything before the call. We will look at documents together in real time.

Examples of documents you may be asked to show during your appointment (depending on your needs may include any of the following:

– ID or driver’s license
– Proof of income (paystub, benefits statement, or bank statement)
– Rent invoice, lease, or eviction notice
– Utility bill or shut-off notice
– Childcare invoice
– Any document related to the support you’re requesting

Will you have your documents ready to show?

Yes

I may need help gathering them

Not sure

SECTION 8: Consent & Next Steps

Do you agree to be contacted by Empowered Path Alliance regarding support and resources?

Yes

I confirm the information I provided is accurate to the best of my knowledge.

Yes