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26
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HIPAA
Compliance
1
Name
*
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First
Last
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2
Preferred name
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3
Preferred pronouns
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4
Address
*
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Street, City, and Zip Code
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5
In which county do you live?
*
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Example: Buncombe, Madison, Transylvania, Henderson, etc.
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6
Phone Number
Area Code
Phone Number
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7
Email
Please use an address you check often.
example@example.com
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8
Which method of communication do you prefer?
Text
Call
Email
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9
Last 4 of Social Security Number
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10
Date of birth:
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11
Age:
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12
Highest grade level completed:
9th
10th
11th
12th
GED
9th
10th
11th
12th
GED
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13
Name of most recent school that you attended:
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14
Did you complete High School?
*
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YES
NO
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15
Are you currently in school?
*
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YES
NO
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16
Do you have reliable transportation?
YES
NO
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17
Are you currently employed?
YES
NO
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18
How many family members live in your home? (including yourself)
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19
Citizenship Status:
US Citizen
Eligible Non-Citizen
Non-Citizen
US Citizen
Eligible Non-Citizen
Non-Citizen
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20
Please select all that apply:
*
This field is required.
I, or someone in my home, receive Food Stamps or TANF.
I am pregnant or a parent.
I have a disability.
I am in or aged out of Foster Care.
I have an IEP or 504 plan on file with my most recent school.
I have a criminal history.
I did not complete high school.
I am homeless
None of the above.
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21
What are your career and educational goals?
*
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22
What do you want to accomplish in the next 2 years?
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23
Briefly describe a recent success:
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24
What is an important life lesson you have recently learned?
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25
How did you hear about our program?
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26
Are you working with other community organizations? If so, please list below.
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27
Tags
Todo
In Progress
Done
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