EmpowerMEnt Application Question Title * 1. Youth's Legal Name Question Title * 2. Youth's Preferred Name Question Title * 3. Youth's Birthdate Youth's Birthdate Date Question Title * 4. Sex - Assigned at Birth Male Female Question Title * 5. Gender Expression/Identity Male Female Non-binary (Genderfluid,. Gender Non-0conforming, Genderqueer, etc.) Transgender - FTM Transgender - MTF Other Unknown Question Title * 6. Sexual Orientation Gay/Lesbian Queer Bisexual Questioning Homosexual Heterosexual Other Unknown/Has not disclosed Question Title * 7. Race Alaska Native American Indian Asian or Asian American Black or African American White Caucasion Multi-Racial Biracial Other Unknown Question Title * 8. Is the youth at an agency at the time of this referral? If yes, what agency? Question Title * 9. Were you in foster care in Georgia? If not, what state? Yes If not in Georgia, what state? Question Title * 10. Custody County Question Title * 11. DFCS Case Manager Name Question Title * 12. Permanency Plan Adoption Another Planned Permanent Living Arrangement (APPLA) Emancipation Guardianship Living with Other Relative N/A - Adopted Not Sure Reunification Question Title * 13. I have the following documentation Birth Certificate Driver's License Learner's Permit Other (Proof of Citizenship) Social Security Card State ID Voter Registration Green Card/Work Permit 33% of survey complete. Next
