Yield to the King Ministry Intake Screening
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Email *
Interpreter needed? *
Do you have transportation? *
Describe your current situation. *
Services needed (check all that apply) *
Required
Name (first, middle, last) *
0 points
Message telephone (10 digits only) *
Address (street/mailing or place authorized to receive your mail *
Date of Birth *
MM
/
DD
/
YYYY
What is your race/ethnicity? Check all that apply. (answers used for data collection only) *
Required
Marital Status *
Spouses Name
Parental Status (check all that apply) *
Required
Source of Income (check all that apply) *
Required
Education (check all that apply)
Do you have medical/dental insurance? *
Required
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