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Client Survey
Demographic Information
Your Zip Code
(Required.)
What is your gender?
(Required.)
Female
Male
My age is is between the following:
(Required.)
Under 15
16 to 25
26 to 35
36 to 45
46 to 55
56 to 65
Over 65
Enter the gender and age of your children
(Required.)
Gender
Age
Child #1
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child #2
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child #3
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child #4
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child #5
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child #6
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child #7
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Child #8
-- Select an option --
Male
Female
-- Select an option --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
My family's race/ethnicity is;
(Required.)
Black
White
Hispanic
Native American
Asian / Pacific islander
Other (please specify)
My family's primary language is:
(Required.)
English
Spanish
Other (please specify)
My family's household income comes primarily from:
(Required.)
Employment
OWF (Welfare)
SSI
Other (please specify)
