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AACF Initial Intake - Online Survey
Questions marked with a
*
are required
Contact Information
First Name
Last Name
Zip Code
Email Address
Have you received services from AACF before?
-- Select --
Yes
No
Age
16-24
25+
Ethnicity
African American
White
Hispanic
Asian
Other
Phone
City
Purpose or Additional Information
Income
Below $32,600
Above $32,600
Are you seeking help with?
A Job
Housing
Mental Health
Training
Referred By (Name of Agency, Case Manager, and Phone number):
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