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2. Date*
   Date

   Date
4. Head of Household Name*
5. Date of Birth*
7. Primary Phone Number*
8. Email Address*
10. Marital Status*

    1. Single
    2. Married
    3. Separated
    4. Widow/Widower
11. Race*

    1. White
    2. Black/African American
    3. American Indian or Alaskan
    4. Asian
    5. Multicultural/Mixed
    6. Other
12. Gender*

    1. Male
    2. Female
    3. Transgender Female to Male
    4. Transgender Male to Female
    5. Client Does Not Identify Male, Female or Transgender
14. Are you currently pregnant?*

    1. Yes
    2. No
15. Are you a Veteran?*

    1. Yes
    2. No
17. Where did you stay last night?*

    1. Own house or rental
    2. Shelter
    3. Street/Car
    4. Friend/Relative
    5. Hotel
    6. Jail/Prison
18. What was the length of stay?*

    1. One week or less
    2. 2-4 Weeks
    3. 1-3 Months
    4. 4-12 Months
    5. 1 Year or more
20. When was the last time you were stably housed?*
22. Additional Household Members*
    Please list all persons that currently reside in the household along with date of birth.
24. Does anyone in your family have a disabling condition?*
    If anyone in your family has a disability condition please indicate what family member above.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field