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Free Group Registration - Getting To Know You
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12
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HIPAA
Compliance
Language
English (US)
Español
1
PeerType
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2
Name
*
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First Name
Last Name
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3
Phone Number
*
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Please enter a valid phone number.
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4
Email
*
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example@example.com
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5
Housing Status
*
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I'm housed
I'm not housed
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6
Your Date of Birth
*
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7
Your Gender Identity
*
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Male
Female
Non-Binary
Other
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8
Preferred Language
*
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English
Spanish
Armenian
Japanese
Filipino
Mandarin
Farsi
German
Italian
French
Other
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9
If yes, please explain:
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10
How did you hear about us?
*
This field is required.
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11
What are your interests and needs?
*
This field is required.
Peer Mentoring
Legal Services/Justice Involved
Employment Readiness
Housing/Placement
Academic Support
Budget & Financial Planning
Life Skills Training
Recreation and Connectivity
Spiritual Support
Physical Therapy Coach
Android Tablet or Chromebook & VR headset
Other
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12
Insurance Provider
*
This field is required.
Medicare
Medi-Cal
Medi-Medi
Private
Other
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13
If "Private" or "Other" please provide the name of your insurance:
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