Group Session Intake

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Class Name

Attendee

First Name

Last Name

Phone

Phone Type

Street Address

City

State

Zip Code

Is there a second person from your Household attending this session?

Second Attendee

First Name

Last Name

Hidden Fields

Group Session ID

Owner ID

Owner Role/Agency Formula

Contact ID

Counseling/Education ID

Service File ID

Disclosure URL

IsLegacySubmission

TRUEFALSE

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To demonstrate our commitment to equity and our service reach, we are required to collect demographic information from the clients we serve. Please answer the following demographic questions.

1. What is your birth date?

MM/DD/YYYY

2. What gender do you identify as?

3. What is the highest degree or level of education you have completed?

4. What is your monthly household income? (Include income from all sources including employment, child support, social security, pension, etc.)

Annual household income

5. Are you a veteran?

6. Are you active military?

7. Are you living with a disability?

8. Do you need language assistance or an interpreter

9. What language do you primarily speak?

10. What is your current housing arrangement?

11. Do you live in a rural area?

12. How many adults live with you?

13. How many children live with you?

14. What is your current marital status?

15. What best describes your household type?

16. What is your race?

16.1 What is the race of the other person you listed?

17. Are you Hispanic, Latino or Spanish origin?

17.1 Is the other person you listed of Hispanic, Latino or Spanish origin?

18. Were you born outside of the United States?

19. Do you identify with any of the following immigrant or new American communities?

20. Are you a first time homebuyer (you have not owned a home for the past 3 years)?

21. Are you a first generation homebuyer (your parents did not own a home)?

22. How did you hear about us?