Client Characteristic Form
Public Services – Limited Clientele Activities

Please complete sections 1 through 6 on this form. This information for statistical purposes only.

Client Characteristic Form

  • Household Income

  • Please indicate both the number of members living in your household, including yourself and you household income.
  • Race

  • Please note: Hispanic, Latino, and/or Puerto Rican is NOT your RACE. Hispanic, Latino, and/or Puerto Rican is your ETHNICITY. Check which group listed below best pertains to you.
  • Age of Program Participant

  • Gender

  • Who Do You Live With?

  • Do you consider yourself with a severe disability?

 

Verification