Client Information

Date of Entry: Date of Exit: Name: Address: Zip Code: Phone: Birthdate: Age: Sex: Race: Ethnicity: Marital Status:

Length of Stay at Previous Address: Country of Origin (if not U.S.): Number of Times Living in a Shelter: Length of Stay at Previous Shelter Number of Children:

Highest Level of Education: Employment Status: Income Amount at Time of Intake: Income Source at Time of Intake:

Income Amount when Exiting HoG: Income 1 Year from Exiting HoG: Weeks Pregnant: Prenatal Care Prior to Intake at HoG: Domestic Violence Survivor: Veteran Status: Is the Father of the Unborn Child Involved? Father's Highest Level of Education: Father's Occupation: Father's Income (Wage or Salary):

High blood pressure: Diabetes: If Yes, please select your Diabetes Type: Heart disease: Live births: Miscarriages: Diagnosed Disability: Any other medical conditions:

Demographic Information