• Healthy Perspectives - Ubuntu Roots Parenting Program - DEMOGRAPHICS INFORMATION

    Read each question and select the one answer that best describes you. Your response helps us to understand the overall impact of services and activities provided as part of this Children and Youth Behavioral Health Initiative (CYBHI) grant. Your data will be kept confidential. 
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Site/Location*
  • Format: (000) 000-0000.
  • What is your date of birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is your highest level of education?*
  • Which best describes your insurance status?*
  • 3. Which best describes your sexual orientation?*
  • 4. What is your gender identity?*
  • What is your primary language?*
  • Are you a pregnant or expectant mother*
  • Do you live in an urban or rural area?*
  • What is your race?*
  • Are you of Hispanic, Latino/a, or Spanish origin?*
  • Which best describes your housing status?*
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  • Should be Empty: