2024 Request for Services Form
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.
Program Information
What Dress for Success program(s) are you requesting?
StyleHER: I need clothes for a new job or upcoming interview.
HigherHER: I want help with job searching, resume, or career growth.
EmpowerHER: I want to learn and network with other women like me.
If you're attending a Mobile Styling Event, please select StyleHER
For StyleHER/clothing styling, which location would you like to use? (
all of our other programming is offered out of our Norwood location
)
Dress for Success - Wesley Ave. in Norwood, OH
The Care Center - Loveland, OH
(childcare available if planned in advance)
Life Learning Center - Covington, KY
Mobile - I am attending a mobile styling event.
General Information
First Name
Last Name
What is your birth date? (mm/dd/yy)
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
Contact 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
Mobile Phone
Personal Email
What is your preferred method of communication? (Check all that apply)
Email
Phone
Text
How Did You Hear About Us?
Are you being referred by another agency, program, organization, or school?
Yes
No
What agency, program, organization or school did you hear about us from or referred you?
Household Information
PLEASE NOTE:
The following questions will NOT affect your ability to participate in Dress for Success programs. This info helps us to anonymously report group numbers to our funders to support the mission of Dress for Success.
What is your household size?
(the number of people including yourself that you would include in filing your taxes or if you were to apply for benefits, that you currently live with)
1
2
3
4
5
6
7 or more
My TOTAL household income this YEAR/MONTH was:
(estimate total income for anyone that you included in your household size count, including employment income, cash assistance, unemployment, social security etc.)
MORE than: $29,160 a year/$2,430 a month
LESS than: $29,160 a year/$2,430 a month
My TOTAL household income this YEAR/MONTH was:
(estimate total income for anyone that you included in your household size count, including employment income, cash assistance, unemployment, social security etc.)
MORE than: $39,440 a year/$3,287 a month
LESS than: $39,440 a year/$3,287 a month
My TOTAL household income this YEAR/MONTH was:
(estimate total income for anyone that you included in your household size count, including employment income, cash assistance, unemployment, social security etc.)
MORE than: $49,720 a year/$4,143 a month
LESS than: $49,720 a year/$4,143 a month
My TOTAL household income this YEAR/MONTH was:
(estimate total income for anyone that you included in your household size count, including employment income, cash assistance, unemployment, social security etc.)
MORE than: $60,000 a year/$5,000 a month
LESS than: $60,000 a year/$5,000 a month
My TOTAL household income this YEAR/MONTH was:
(estimate total income for anyone that you included in your household size count, including employment income, cash assistance, unemployment, social security etc.)
MORE than: $70,280 a year/$5,857 a month
LESS than: $70,280 a year/$5,857 a month
My TOTAL household income this YEAR/MONTH was:
(estimate total income for anyone that you included in your household size count, including employment income, cash assistance, unemployment, social security etc.)
MORE than: $80,560 a year/$6,713 a month
LESS than:
$80,560 a year/$6,713
a month
My TOTAL household income this YEAR/MONTH was:
(estimate total income for anyone that you included in your household size count, including employment income, cash assistance, unemployment, social security etc.)
MORE than: $90,840 a year/$7,570 a month
LESS than:
$90,840 a year/$7,570 a month
a month
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
Do you have any children?
Yes
No
Do you have children under the age of 18 living with you?
Yes
No
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
Thanks so much for taking the time to share your information.
We are so excited to meet with you and to celebrate your journey!
Reviewed
Choice A
Contact Information