THE GARDEN - Youth Intake Form

THE GARDEN - Youth Intake Form

Youth Member Information

1. First Name

2. Middle Name

3. Last Name

4. Name You Go By

5. Street Address

6. City

7. State

8. Zip Code

9. Preferred Communication Method

EmailWhatsAppText

10. Email

11. WhatsApp Number

12. Mobile Phone

13. I consent to receive information by text message and/or WhatsApp from Connect Community. (Click here to view Terms & Conditions and Privacy Policy)

YesNo

14. Date of Birth

15. Are you 18 years old or older?

YesNo

16. Language I prefer to speak

16-a. Please specify other preferred language

17. Language(s) I speak

English	Spanish	Mandarin
Cantonese	Vietnamese	Tagalog
Arabic	Swahili	French
Pashto	Persian Dari	Urdu
Amharic	Somali	Kinyarwanda
Oromo	Other

17-a. Please specify other language(s) you speak

18. Gender

18-a. Please describe other gender identity

19. Pronouns

she/her/hers	he/him/his
they/them/theirs	Not listed
Prefer not to answer

19-a. Please specify not listed pronouns

20. Race/Ethnicity

WhiteHispanic, Latino, or Spanish originBlack or African AmericanEast AsianSouth AsianAmerican Indian or Alaska NativeMiddle Eastern, Southwest Asian, or North AfricanNative Hawaiian or Other Pacific IslanderSome other race, ethnicity or originPrefer not to answer

20-a. Please specify other race, ethnicity, or origin

White

Eg: German, Irish, English, Italian, Polish, French, etc.

Hispanic, Latino, or Spanish origin

Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc.

Black or African American

Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc.

East Asian

Eg: Chinese, Vietnamese, Korean, Japanese, Filipino, etc.

South Asian

Eg: Indian, Bangladeshi, Nepalese, etc.

American Indian or Alaska Native

Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Nome Eskimo Community, etc.

Middle Eastern, Southwest Asian, or North African

Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc.

Native Hawaiian or Other Pacific Islander

Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc.

21. Country of origin

22. Are you enrolled in school?

YesNo

22-a. School Name

22-a-1. Please specify other school name

22-b. Grade

22-c. Highest level of education completed

23. Household Type

Live with family	Live with romantic partner(s)
Unstable housing	Live with roommate(s)
Live alone	Other living situation/arrangement

24. Number of People in Household

25. How did you find us?

Parent/Guardian Information

26. First Name

27. Middle Name

28. Last Name

29. Preferred Name

30. Address

Use Youth's Address for Parent/Guardian

31. Street Address

32. City

33. State

34. Zip Code

35. Preferred Communication Method

EmailWhatsAppText

36. Email

37. WhatsApp Number

38. Mobile Phone

39. Parent/Guardian Preferred Language

39-a. Please specify other Parent/Guardian Preferred Language

40. Relationship to Youth

41. Is this Parent/Guardian an Emergency Contact?

YesNo

Emergency Contact Details

42. Emergency Contact Full Name

43. Emergency Contact Relationship to Youth

44. Emergency Contact Number

45. Emergency Contact Preferred Language

45-a. Please specify other Emergency Contact Preferred Language

46. Communication with Emergency Contact

47. Name to refer to you by:

48. Pronouns to refer to you by:

49. Gender to identify you as:

50. Notes/other information: