General Questions

Please help us improve our programs by answering a few questions.

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* 1. Today's Date:

Date
Time

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* 2. Address

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* 3. What is your date of birth?

Date

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

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* 5. What is your approximate average household income?

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* 6. Last Grade Completed:

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* 7. Last Year In School (e.g. 1999):

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* 8. Living Arrangements:

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* 9. Are you interested in any of our other services? (Select all that apply)

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