Client Demographic FormPlease enable JavaScript in your browser to complete this form.Date:GenderMaleFemaleEthnicityHispanic or LatinoNot Hispanic or LatinoRaceWhiteBlack or African AmericanHispanic or LatinoAsianAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderEthnicity not Listed AboveAge5-1314-1819-3131-4445-6061+Program:Adult Grief CounselingAdult Support GroupsYouth & Family Grief CounselingZIP Code: *Annual Household/Family Income *Less than $14,079$14,080 - $18,941$18,942 - $23,803$23,804 - $28,665$28,666 - $33,527$33,528 - $38,389$38,390 - $43,251$43,252 - $48,113$48,114+Number of people in your household (persons in a household are defined as those who live in the same dwelling and are related by blood or marriage) : *Primary Language spoken in your household: *CommentSubmit