YW Strive Intake Questionnaire

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Thank you for your interest in the YW Strive program! Please answer the questions below as honestly as possible.

Individual response data will not be shared. Your answers are required for funding purposes - by answering in full, you will help the YW Strive program expand and improve.

For any questions about the YW Strive program or questionnaire, please contact Farrah Foreman, Economic Empowerment Counselor, at fforeman@ywca-neny.org or Katrina Garcia at kgarcia@ywca-neny.org

First name *

Last name

Email Address (if applicable)

Phone Number (n/a if not applicable) *

Birthdate *

YYYY

What gender do you identify as? Check all that apply. *

Female

Male

Nonbinary

Prefer not to answer

Other:

Required

What race do you identify as? Check all that apply. *

American Indian or Alaska Native

Asian

Black/African descent

Hispanic/Latino/Latinx

Middle Eastern/North African

White/European descent

Multiracial

Prefer not to answer

Other:

Required

What zip code do you live in? If homeless, please input "HH" *

What agency referred you to this program? (if applicable)

If you were referred: Are you OK with us sharing information with the Referring Agency about your progress in YW Strive?

Yes

Maybe

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