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.
Filing Out This Form
Are you filling out this form for yourself or a client?
Which location will you be utilizing?
Dress for Success - Wesley Ave. in Norwood
The Care Center - Loveland
Life Learning Center - Covington
Please provide your name and agency if applicable. Continue filling out the form for your client to the best of your ability.
What is your birth date?
What is your Race/Ethnicity?
Black or African American
Hispanic or LatinX
Other Pacific Islander
Select if you are Hispanic
District Of Columbia
Northern Mariana Islands
What is your preferred phone number?
What is your preferred email?
What is your preferred method of communication? (Check all that apply)
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)
If you are here for StyleHER, what are you here for?
I am not here for StyleHER
Are your basic needs being met? For example, housing, food insecure, mental health.
How Did You Hear About Us?
How did you hear about Dress for Success?
Are you being referred by another agency, program or organization?
What agency, program or organization has referred you?
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?)
Number of people in household? (If you are in congregate/group housing you are a household of 1.
Have you ever had children?
Number of children under 18 currently living with you?
Are you currently employed?
Are you paid hourly or 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
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)
Do you receive any public assistance? (For example: SNAP, Medicaid, SSI, SSA, unemployment)
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.
Have any of the following areas been barriers in your job search or maintaining employment?
Identification/Social Security Card/Birth Certificate
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 do not agree
member of the DFSC team will be in contact with you soon for further assistance.
If you're requesting an employment appointment, please upload your employment verification (pay stub, schedule, offer letter, etc.).