Demographic Intake Survey

Demographic Intake Survey
Please complete this survey to help us better understand the demographic characteristics of our participants.
Full Name
First NameLast Name
What is your age group?
What is your gender?
Other
What is your ethnicity?
Other
What is your highest level of education completed?
Other
What is your current employment status?
Other
What is your marital status?
Other
How many people live in your household (including yourself)?
What is your annual household income range?
Which language(s) are spoken at home?
Other
In which country do you currently reside?
How would you describe your overall health?
Please indicate your agreement with the following statements:
Rows Strongly Disagree Disagree Neutral Agree Strongly Agree
I feel included in my community.
I have access to the resources I need.
I am satisfied with my current living situation.
Should be Empty:

Select theme:

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I feel included in my community.
I have access to the resources I need.
I am satisfied with my current living situation.