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The following is used for conversational purposes only and is optional.
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Please answer the below questions so that we may better assist you in finding resources in your area. 

Por favor responda las siguientes preguntas para poder ayudarlo mejor a encontrar recursos en su área.

Would you like to proceed in English or Spanish?
¿Le gustraia proceder en ingles o en espanol? *
How do you identify your gender?
¿Cómo identificas tu género? *
Are you currently or have you been in the military service?
¿Está actualmente o ha estado en el servicio militar? *
Do you have a disability?
¿Tiene usted alguna discapacidad? *
What is your age?
¿Cuál es su edad? *
Do you currently have health insurance?
¿Tiene usted Seguro Médico? *

Do you have children under the age of 18 in your household?
¿Tiene niños menores de 18 en su hogar?

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