CARE for AIDS Client Intake Data
Demographics
Name of Community/ Center *
Program Phase (for pilots)
Program Year
Region
Name *
Your answer
Age *
Your answer
ID Number *
Your answer
Gender *
How many dependent children do you have under the age of 19 years old? *
Do you accept Jesus as your personal Lord and Savior?
OBSERVATION: Comments (if any) regarding client's answer to previous question:
Your answer
Do you regularly attend a local church?
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