PACT - RECIPIENT ENTRANCE SURVEY

Behavioral Health Client Entrance Survey

A. Cultural Information

Male

Female

Transgender

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiracial

Other

Under 18

18-24

25-34

35-44

45-54

55-64

65+

0 to 6 months

6 months to 1 year

1 to 2 years

2 years or more