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* 1. What is your gender?

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* 2. What is your child's gender?

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* 3. Please describe your child's race/ethnicity.

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* 4. Which of the following best describes your current relationship status?

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* 5. Which of the following categories best describes your employment status

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* 6. How many people currently live in your household?

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* 7. What services will we provide to you?

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* 8. Please describe the behaviors of the child

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