Request for Services
Welcome to Dress for Success Cincinnati! The purpose of this intake form is to begin a trusted relationship together to tailor our programs in support of your needs. We realize that some of the following questions may feel private, but they are collected to assist in anonymous reporting to our grant funding partners who help us realize the Dress for Success mission and to ensure that we provide you with the best services possible.
Please select your language.
Filing Out This Form
Are you filling out this form for yourself or a client?
Self
Client
Which location will you be utilizing?
Dress for Success - Wesley Ave. in Norwood
The Care Center - Loveland
Life Learning Center - Covington
Referral Information
Please provide your name and agency if applicable. If you selected Self, please enter the name of the agency that suggested you complete this form. Continue filling out the form for your client to the best of your ability.
General Information
First Name
Last Name
What is your birth date?
What is your Race/Ethnicity?
American Indian
Alaskan Native
Asian
Black or African American
Hispanic or LatinX
Native Hawaiian
Other Pacific Islander
White
Multiple Ethnicity
Other
Other Details:
Select if you are Hispanic
Yes
Address Information
Street Address
City
State
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
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code
County
Please select...
Hamilton
Butler
Clermont
Warren
Kenton
Boone
Campbell
Dearborn
Franklin
Other
Intake
What is your preferred phone number?
Please select...
Mobile
Home
Mobile Phone
Home Phone
What is your preferred email?
Please select...
Personal
Alternate
Work
Personal Email
Alternate Email
Work Email
What is your preferred method of communication? (Check all that apply)
Email
Phone
Text
What Dress for Success program(s) are you here for today?
StyleHER - interview and employment styling and attire
HigherHER - Career Development Program
HigherHER - Career Center
EmpowerHER - formerly Professional Women's Group (PWG)
Other
Other Details
If you are here for StyleHER, what are you here for?
Interview Styling
Employment Styling
Internship Styling
I am not here for StyleHER
Basic Needs
Are your basic needs being met? For example, housing, food insecure, mental health.
Yes
No
How Did You Hear About Us?
How did you hear about Dress for Success?
Are you being referred by another agency, program or organization?
Yes
No
What agency, program or organization has referred you?
Demographic Information
PLEASE NOTE:
The following questions will not affect your ability to participate in Dress for Success programs. The information requested is ONLY collected to aid in anonymous and aggregate reporting for grant funders who partner in the Dress for Success mission. Please let us know if you have any questions or concerns. We are here to help you.
Are you the Head of Household? (Are you financially responsible for yourself and those who may live with you?)
Yes
No
Number of people in household? (If you are in congregate/group housing you are a household of 1.
)
1
2
3
4
5+
Have you ever had children?
Yes
No
Household
Number of children under 18 currently living with you?
0
1
2
3
4
5+
Employment
Are you currently employed?
Yes
No
Are you paid hourly or salary?
Hourly
Salary
What is your hourly rate?
$9 per hour or below
$10-12 per hour
$13-15 per hour
$16-18 per hour
$19-21 per hour
more than $21 per hour
Other:
Other Details:
What is your annual salary?
0 - $8,999
$9,000 - $14,999
$15,000 - $24,999
$25,000 - $34,999
$35,000 and above
Where are you employed?
(Dress for Success will NOT contact your employer)
Annual Household Income
What is your annual household income? (Estimate total income for all members of your household)
Public Assistance
Do you receive any public assistance? (For example: SNAP, Medicaid, SSI, SSA, unemployment)
Yes
No
Please note that The Care Center - Loveland offers childcare during your appointment
Do you need assistance with any of the following in order to make it to your Dress for Success Cincinnati appointment? Please check all that apply.
Childcare
Transportation
None
Other:
Other Details:
Have any of the following areas been barriers in your job search or maintaining employment?
Childcare
Education/Diploma
Experience/Skills/Training
References
Resume
Job Listing/Opportunities
Transportation
Identification/Social Security Card/Birth Certificate
Mailbox
Phone Number
Email Address
Housing/Residence
Health/Disability
Vision/Glasses
Computer Access
Criminal Convictions
Other
None
Media Release
We want to celebrate you!
From time to time, Dress for Success Cincinnati or its affiliate Portaluca, or others acting on their behalf may take and use photographs, video and audio recordings, in printed or digital form, such as the DFSC Newsletter, Website, Facebook, Instagram and/or Twitter, etc. and its activities for various audiences. I agree that all pictures taken of me in connection with my activities at or with DFSC become the property of DFSC and will not be returned. I also agree that DFSC: a) Will not pay me for the use of any picture containing my likeness; and b) May keep and use any images or recordings containing my likeness and voice on record until I revoke my consent; and c) May use my first name in connection with the above uses.
I agree
I do not agree
A
member of the DFSC team will be in contact with you soon for further assistance.
File Upload
If you're requesting an employment appointment, please upload your employment verification (pay stub, schedule, offer letter, etc.).
Attachment
Updated 4-13-2022
Reviewed
Choice A
Contact Information