Client Registration
This form gathers your basic contact and demographic information.
Email address *
Name *
Your answer
Home Address *
Your answer
Phone Number *
Your answer
Age *
Your answer
Gender Identity *
Your answer
Gender Pronouns *
Relationship Status *
Emergency Contact (Name and Number) *
Your answer
Who lives with you? *
Your answer
What kind of work do you do? *
Your answer
Have you served in the military?
Are you a mental health care provider?
Who referred you to me?
Your answer
Please provide contact information for any health care provider you might like me to communicate with *if and only if* you request/release me in writing to do so.
Your answer
Would you care to share your religious or spiritual beliefs?
Your answer
What do you do for exercise?
Your answer
Any additional comments?
Your answer
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