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Get DHR IMPACT Resource Family Evaluation Questionnaire 2005-2024

S Inventory. This confidential information is used as a part of your family assessment. There are no right or wrong answers. If you have any questions or concerns about any question, please contact your IMPACT leader or discuss it during your home consultation. If you run out of space in answering a question, please feel free to add additional sheets. FAMILY NAME: STREET LN 1: STREET LN 2: CITY: COUNTY: STATE: ZIP: PHONE: EMAIL ADDRESS (S): Heads of Household NAME: AGE: DATE OF BIRTH: SEX: ETHNI.

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