LRCMHC Client Information Sheet
Please complete the following information and click submit.
Full Name *
Your answer
Address *
Your answer
City *
Your answer
Zip Code *
Your answer
County of Residence *
Your answer
Type of Residence *
Date of Birth (Must be 21+) *
MM
/
DD
/
YYYY
Gender *
Social Security Number *
Your answer
Marital Status *
Phone *
Your answer
Alternate/Message Phone (if any)
Your answer
Email Address *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Emergency Contact Relationship *
Your answer
Race *
Ethnicity *
Employment Status *
How did you learn about us? *
Your answer
Do you have Medicaid? *
Do you have other insurance? *
If you have other insurance, who is your insurance carrier?
Your answer
Reason for Requesting Services *
Your answer
Are you a veteran? *
Are you currently homeless? *
If you're currently homeless, where did you stay last night?
Your answer
Other Comments
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