Register 2018-05-01T13:34:53+00:00

Client Registration Form

We respect your privacy!

We know we ask for a lot of information below. Please know that we are committed to respecting your privacy, and need this information to deliver the best service to you. If you prefer not to provide particular information or would like discuss, send us an email at

Gender MaleFemaleOther

Age range1818-2425-3435-4445-6060+

Marital StatusSingleMarriedDivorced/SeparatedWidowed

Children?YesYes I'm expectingNo

EthnicityCaucasianNative AmericanAsianAfrican-AmericanHispanicMultiracialOther

Housing Status Stable housingUnstable housingHomelessOther

Housing Status Emergency shelterAbandoned buildingStructure lackingVehicleOut of doors (street, tent, etc.)Transitional housingDoubled upOther

Are you a veteran?YesNo


SERVICES NEEDEDTransportationWorkshopsTrainings