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Services Questionaire
Back to your county
Submitted by
funnel
on Thu, 11/16/2017 - 8:49am
Which specific kind of parentPRO programs and services would interest you or your family the most? (Select all that apply)
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Learn how to support your child’s health
Learn how to support your health, including health during pregnancy
Decrease stress of parenting
Know how to help your child’s development
Help get your child ready for school
Help parents meet their life goals – such as employment, education, and housing
Tell us about your family. Choose the ONE that best describes your family.
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Pregnant with first child and less than 29 weeks pregnant
Pregnant with first child and more than 29 weeks pregnant
Have at least one child five years or younger
Have a six year old child in kindergarten, but no younger children
None of the above
Are you eligible for WIC and/or Medicaid Soonercare?
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Yes
No
Don’t know
Language preference for services
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English
Español
Is your child Native American?
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Yes
No
Please check any of the following questions if true
My child is between the ages of 13-21.
My child is enrolled in a educational institute.
What is your name?
First Name
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Last Name
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What is your phone number?
*
What is your e-mail address?
*
