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* 4. What gender do you identify as?

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* 5. Full Name (First, Last) 

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* 7. Date of birth

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* 8. In what ZIP code is your home located?

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* 9. Current home address (house number, street, city)

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* 10. What grade are you currently in?

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* 11. What school do you currently attend?

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* 12. Do you have access to a computer where you live?

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* 13. Do you have access to high speed internet/hot spot where you live?

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* 14. Current working phone number

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* 15. Email address

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* 16. Social media contact information (IG/FB)

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* 17. List your emergency contact(s) (name, phone number, and relationship to you)

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* 18. Are you currently employed?

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* 20. Have you been tested for the Corona Virus in 2020?

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* 21. Have you been diagnosed with the Corona Virus in 2020?

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* 22. List any current health conditions you have that may prevent you from engaging with YEAH in person. 

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* 23. List any current mental health diagnosis you have.

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* 24. Where do you go to see a doctor or for your medical appointments? & what is your primary care doctor's name? (if you have one). 

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* 25. Are you currently in crisis or have an emergency situation that needs to be addressed immediately? (if your safety is at risk, dial 911)

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* 26. Do you have a current safety plan? (A plan if you are ever in crisis)

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* 27. Are you involved with or receive services from any social service or community support agency? (DHS, CUA, Probation, Mental HealthTreatment, Drop in Center)

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* 28. Is there anything else you want us to know? 

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