Enrolled Demographics Agency Name Agency Person Reporting Today's Date MM slash DD slash YYYY Month ReportingPlease Select...JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAGE17 and under 18 - 23 24 - 30 31 - 40 41 - 50 51 - 61 62 and over GENDERFemale Male No Single Gender Questioning Transgender Client Refused/doesn't know ETHNICITYNon-Hispanic / Non-Latin(a)(o)(x) Hispanic / Latin(a)(o)(x) Client Refused RACE (May select more than one option)American Indian, Alaska Native, or Indigenous Asian or Asian American Black, African American, or African Native Hawaiian or Pacific Islander White Other Client refused * This element will not add to total enrolled. FunderIVRS Medicaid/MCO MHDS Region Other Awaiting Funder CommentsThis field is for validation purposes and should be left unchanged.
