All About You

Please complete the form below and submit it. You will be contacted with available dates and to complete the intake process.

Name:
Address:
City:   State:   Zip:
Phone: May we call and leave a message at this number? Yes No
Alt. Phone: May we call and leave a message at this number? Yes No
Email: Date of Birth:
Age: 18-25  26-35  36-45  46+
Sex: Male  Female
Ethnicity:  White   Hispanic  African-American  
                 American-Indian  Asian  Prefer not to answer
Marital Status: Single  Engaged  Married 
                       Widowed  Separated  Common Law  Divorced
Attending the workshop with your partner or spouse? Yes No

IF YOU ARE MARRIED… How many years married?
0-4 yrs.   5-9 yrs.   10-20 yrs.   20-30 yrs.  30+ yrs.

Please rate your current satisfaction level with this marriage:

Very Satisfied Satisfied   Somewhat Satisfied   Unsatisfied  Very Unsatisfied

Highest Level of Education:

No schooling or some elementary

Completed elementary (grade 5)                   

Completed middle school (grade 8)  

Completed high school or GED

College: 2 year or associate degree

College: 4 year degree

How many children live in your household?  0   1  2  3  4  5  6+

What are the ages of your children? Select all that apply
Infant Toddler Preschool Elementary School Middle School High School

Where were you born?
North America
South America
Asia
Europe
Central America
Africa

Do you have a child with your current partner?

Are you pregnant now?

Please tell us about your personal income. Do not include your partner’s income.
Under $4,999
$5,000-$9,999
$10,000-$14,999
$15,000--$19,000
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000-$69,999
Over $70,000

Choose ONE from the list to let us know where you heard about the workshop.
Radio Ad
Television Ad
Poster/Flyer
Church
Friend
Family
Internet
Other

Choose a location for the class.
Bronzeville Joliet Lawndale