Adult Intake Participant ID#*Instructions: Please mark your answer to the following questions about yourself. Your answers will be kept confidential. If you have any questions, please notify the program staff.1. What is your sex?* Female Male 2. What is your age in years?*3. What is your current relationship status?* Single Committed Relationship (Not Married) Married 4. Have you ever been separated?* Yes No 5. Have you ever been divorced?* Yes No 6. Have you ever been widowed?* Yes No 7. Are you of Hispanic, Latino or Spanish ethnicity?* Yes No 8. What is your race?* American Indian or Alaska Native Asian American / Asian African American / Black Bi-racial European American / White Native Hawaiian / Pacific Islander Other – Please List 9. What is the highest level of education you have attained?* Did Not Finish High School High School Diploma / GED Trade school / Technical Certificate Associate’s Degree Bachelor’s Degree Master’s Degree / Advanced Degree 10. What is your current employment / job status?* Full-Time Employment (35 or more hours a week) Part-Time Employment (1-34 hours a week) Employed, but number of hours change from week to week Temporary, occasional, or seasonal employment or odd jobs for pay Not currently employed 11. If you are NOT currently employed, are you: Actively looking for work Retired Disabled NOT actively looking for work 12. What is your current monthly income?* Nothing, I am unemployed $100 – $799 $800 – $1,599 $1,600 – $2,499 $2,500 – $3,299 $3,300 – $4,099 $4,100 – $4,999 $5000 or more 13. Are you currently incarcerated (in jail)?* Yes No 14. How many children do you have? Mark all that apply.How many biological children?How many step-children?How many grandchildren?How many foster children?How many adopted children?15. How many of these children have special needs?What is / are the special needs? (Choose All That Apply)ADD/ADHDAphasia/DysphasiaApraxia/DyspraxiaAuditory ProcessingAutism/AspergersCystic FibrosisCerebral PalsyDevelopmental DelaysDown SyndromeDyslexiaEmotional/Behavior DisordersFetal Alcohol SyndromeFragile "X"Hearing ImpairedLearning DisabilitiesIntellectual DisabilityNeurological DisabilitiesSeizure DisorderSupport GroupsVisual ImpairmentOther – Please List BelowCAPTCHA Δ
