Demographics
Name
Date of Birth
Social Security Number
Primary Street Address
City, State, Zip
County
Phone Number
Email Address
Race
Ethnicity
Sex
Select
Male
Female
Intersex
Prefer not to answer
Gender Identity
Select
Man
Woman
Nonconforming
Prefer not to answer
Preference:
Relationship Status
Select
Single
Married
Divorced
Widowed
Separated
Prefer not to answer
Language
Select
English
Spanish
French
Other
Other Language:
Dialect (if applicable):
Translator Needed
Select
Yes
No
Provided
Dx Disability
Select
Emotional
Intelectual/Developmental
Learning/Cognative
Physical
Sensory
Other
Prefer not to answer
please specify:
Dx Mental Illness or Addiction
Select
Addiction
MI
Prefer not to answer
please specify:
Criminal History
Select
Yes
No
Prefer not to answer
If yes, please specify:
Employment Status
Select
Employed
Unemployed
Student
Retired
Prefer not to answer
Household Income
Select
Less than $25,000
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 or more
Prefer not to answer
# of People in Household
# of Dependent Children
# of Children in Household
# of Other Dependents
Highest Level of Education
Select
Less than High School
High School Graduate
Some College
Bachelor's Degree
Graduate Degree
Prefer not to answer
Medical Insurance Type
Select
Private Insurance
Medicaid
Medicare
Uninsured
HIP
Military
Prefer not to answer
Insurance Provider:
Emergency Contact Name
Emergency Contact Phone
Prior Involvement with Iris Family Support Center
Select
Yes
No
Prefer not to answer
If yes, please specify:
Other Information