You can always press Enter⏎ to continue
Welcome

Welcome

Hi there, please fill out and submit this form.
  • 1

    Thank you for your interest in Dad and Company: Strengthening the Parenting Team. This program is designed to strengthen family dynamics by building the skills of fathers and the co-parenting team that supports them, so parenting becomes more consistent, more collaborative, and more child-centered.

    The primary applicant for this program is the dad.

    If you are completing this form on behalf of a dad, you must be able to answer every question as the dad would answer it. If you cannot complete the form from the dad’s perspective, please have him complete the form directly. Before you begin, please indicate whether you are the dad completing this form or someone completing it on his behalf.

    Press
    Enter
  • 2
    Select the option that best describes who is completing this form. This helps us make sure the information reflects the dad’s voice and that we follow up with the right person.
    Press
    Enter
  • 3
    Enter your name if you are completing this form on behalf of a dad. This helps us know who submitted the form and how to follow up if we have questions.
    Press
    Enter
  • 4
    Enter your email address so we can follow up with you about next steps, scheduling, and enrollment information.
    Email Verified

    The verification code has been sent to some@email.com
    Please check your mailbox and paste the code below to complete verification

    Didn't receive verification code?or
    Receiving the email may take a few minutes, thank you for your patience!
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Enter the dad’s full name as it should appear in our records and any program documents.
    Press
    Enter
  • 7
    Enter the dad’s email address. We will use this to share class details, confirmation information, and next steps.
    Email Verified

    The verification code has been sent to some@email.com
    Please check your mailbox and paste the code below to complete verification

    Didn't receive verification code?or
    Receiving the email may take a few minutes, thank you for your patience!
    Press
    Enter
  • 8
    Enter your date of birth. This helps us confirm eligibility and ensure we have the correct participant information for enrollment records.
    -
    Pick a Date
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Press
    Enter
  • 11
    Press
    Enter
  • 12
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 13
    Select the county where you currently live. This helps us confirm service area eligibility and plan classes and support in the right locations.
    Press
    Enter
  • 14
    Select the option that best reflects your current work situation. This helps us understand scheduling needs and connect you to the right support if employment is a goal.
    Press
    Enter
  • 15
    Choose the work-related issue that could make it hardest for you to attend sessions consistently. This helps us plan around real schedules and reduce barriers to participation.
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Press
    Enter
  • 18
    Press
    Enter
  • 19
    Choose the format that works best for you right now. This helps us plan class options that are accessible for dads and their co-parenting teams.
    Press
    Enter
  • 20
    Select the time that would make it easiest for you to consistently attend and fully participate. This helps us schedule classes that match the needs of dads and their co-parenting teams.
    Press
    Enter
  • 21
    Press
    Enter
  • 22
    A co-parent is anyone who shares parenting responsibilities for your child, whether you live together or not. Choose the option that best reflects your situation right now.
    Press
    Enter
  • 23
    Press
    Enter
  • 24
    Press
    Enter
  • 25
    Press
    Enter
  • 26
    This refers to a court order or legal agreement that outlines custody, visitation, or parenting time. If you have an informal arrangement but nothing through the court, choose “No.”
    Press
    Enter
  • 27
    These questions help us understand the boundaries that may affect communication and participation, so we can respond appropriately.
    Press
    Enter
  • 28
    Select the option that most closely matches the current limits in place. This helps our team understand what communication boundaries must be respected when we follow up and when considering participation options.
    Press
    Enter
  • 29
    Share only what you feel comfortable sharing. A brief, general note helps our team contact you in the safest and most appropriate way, including respecting any communication limits that may be in place. Do not include detailed case information.
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • 30
    Choose the option that most closely matches how parenting is organized right now. This helps us understand your parenting team and tailor support to your situation.
    Press
    Enter
  • 31
    Press
    Enter
  • 32
    Enter the number of children you are currently raising, supporting, or sharing parenting responsibilities for. This includes children you live with and children you parent from another household.
    Please Select
    • Please Select
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10+
    Press
    Enter
  • 33
    Press
    Enter
  • 34
    Press
    Enter
  • 35
    This question is about what is recorded on the birth certificate for any child born in Georgia. If you are unsure what the certificate says, select “Not sure.”
    Press
    Enter
  • 36
    Answer based on any child you have who was born in Georgia. If you are unsure what legitimation means or whether it has been completed, choose “Not sure.”
    Press
    Enter
  • 37
    Choose the option that best matches where you are right now with legitimation in Georgia. This helps us understand what support or information may be most helpful as part of Dad and Company.
    Press
    Enter
  • 38
    Select any items that apply to your current situation. This helps us understand what structures or agreements are already in place so we can connect you to the most relevant support and class experience.
    Press
    Enter
  • 39
    Think about the past few weeks and choose the option that best reflects how consistent your parenting time has been. This helps us understand your current level of access and routine with your child.
    Press
    Enter
  • 40
    Legitimation can feel confusing if you have never had to deal with it. Let us know if you would like basic information about what it means in Georgia and what next steps typically look like, so we can connect you to the right guidance and resources.
    Press
    Enter
  • 41
    Select the concern that feels most pressing right now. Your answer helps us understand what may be getting in the way and what kind of guidance or support would be most useful.
    Press
    Enter
  • 42
    Share any brief details you believe would help us support you, connect you to the right resources, or follow up in a way that fits your situation. Share only what you feel comfortable sharing.
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • 43
    Use 1 to reflect a relationship that feels very difficult or strained right now, and 10 to reflect a relationship that feels strong, respectful, and collaborative. Choose the number that best matches your current reality.
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    Very Difficult
    Strong and Respectful
    Press
    Enter
  • 44
    Rate your communication as it is today, not how you want it to be. A 1 reflects frequent conflict, avoidance, or confusion, and a 10 reflects clear, respectful communication that stays focused on the child.
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    We avoid or argue
    We communicate clearly
    Press
    Enter
  • 45
    Think about disagreements or tense moments when they come up. A 1 reflects that conflict usually escalates or feels hard to manage, and a 10 reflects that you can stay calm, communicate clearly, and work toward a solution without things getting bigger.
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    Not confident
    Very confident
    Press
    Enter
  • 46
    Select the areas that create the most stress or conflict right now. Your choices help us focus the class experience on the skills and strategies that will be most useful to you and your co-parenting team.
    Press
    Enter
  • 47
    Choose the option that best reflects where you are today. This helps us understand your readiness for change and how to support you in taking the next step.
    Press
    Enter
  • 48
    Describe what you would hope your child experiences if co-parenting became healthier, more consistent, or less stressful. You can keep it simple and focus on everyday life, routines, emotions, or school and behavior.
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • 49
    Choose the number that best reflects your readiness right now. A 1 means you do not feel ready to engage in co-parenting at this time, and a 10 means you feel fully ready to take steps toward a healthy, child-centered co-parenting relationship.
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    Not ready
    Fully Ready
    Press
    Enter
  • 50
    Press
    Enter
  • 51
    Share anything you think would help the facilitator support you well during the program. You can keep it general and focus on what you need to stay engaged, learn effectively, or feel respected in the space.
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • 52
    Yes, you may contact me about Dad and Company
    Press
    Enter
  • 53
    Yes, send me resources
    Press
    Enter
  • 54
    Press
    Enter
  • Should be Empty:
Question Label
1 of 54See AllGo Back
close