Demographic Information Form

Demographic Information Form
Why we collect this information

DRIVEN Neuro is a 501(c)(3) non-profit organization. We use demographic information for grant applications, donor reporting, sponsorship opportunities, and other funding purposes. Your responses help us secure resources to continue providing services.

Providing this information is voluntary, and you may select multiple options, “Other”, or “Prefer Not to State” where applicable.
Disability and/or Injury Information (Select all that apply)

Other
Year of Primary Diagnosis or Injury
Gender

Other
Military / First Responder Status (Select all that apply)
Preferred Spoken Language
Number of People in Your Household
Total Household Income (Annual)
How Did You Hear About DRIVEN Neuro?

Other
Please indicate the specific facility, organization, website/app, or DRIVEN Neuro client where you first learned about DRIVEN Neuro:
Ethnicity (Select all that apply)

Other
Primary Transportation Type

Other
Consent for Data Use

I understand that my demographic information will be used by DRIVEN Neuro staff only as necessary to provide care. Some data may be used for grant applications, donor reporting, sponsorship opportunities, and other funding purposes. Your name will not be used in conjunction with demographic data. For these purposes, we will use either summarized demographic data for all clients or anonymize it so that personally identifiable information is removed. By signing below, I consent to the use of my data as described.
DRIVEN Neuro Client Name

First NameLast Name
Designated Signer Name (if applicable)

First NameLast Name
Parent/Guardian Name (for minors under the age of 18) (if applicable)

First NameLast Name
Client, Parent/Guardian, or Designated Signer's Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Demographic Information Form

Consent for Data Use