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Client Admission Information Form
Client Admission Information Form
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17Questions
Client Admission Information Form
  • 1
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  • 2
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  • 3
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    Pick a Date
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  • 4
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 5
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  • 6
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  • 7
    Please answer each option
    Yes, Text reminders
    • Yes, Text reminders
    • No, Text reminders
    Yes, Voice reminders
    • Yes, Voice reminders
    • No, Voice reminders
    Yes, Email reminders
    • Yes, Email reminders
    • No, Email reminders
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  • 8
    Administrative Sex
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  • 9
    -- Select Gender Identity --
    • -- Select Gender Identity --
    • Male
    • Female
    • Transgender Male/ Trans Man/ FTM
    • Transgender Female/ Trans woman/MTF
    • Genderquuuuer, neither exclusively male nor female
    • Other, please specify no next screen.
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  • 10
    Please Specify Gender Identity
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  • 11
    -- Select Sexual Orientation --
    • -- Select Sexual Orientation --
    • Straight or heterosexual
    • Lesbian, gay, homosexual
    • Bisexual
    • Unknown
    • Other, please specify
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  • 12
    Please Specify Sexual Orientation
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  • 13
    -- Select your race --
    • -- Select your race --
    • American Indian or Alaska Native
    • Asian
    • Black or African American
    • Hispanic or Latino
    • Native Hawaiian or other Pacific Islander
    • White or Caucasian
    • Other, please specify
    • Choosing not to answer
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  • 14
    Please Specify Race
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  • 15
    English
    • -- Select Language --
    • English
    • Afrikaans
    • Albanian
    • Arabic
    • Armenian
    • Basque
    • Bengali
    • Bulgarian
    • Catalan
    • Cambodian
    • Chinese (Mandarin)
    • Croatian
    • Czech
    • Danish
    • Dutch
    • Estonian
    • Fiji
    • Finnish
    • French
    • Georgian
    • German
    • Greek
    • Gujarati
    • Hebrew
    • Hindi
    • Hungarian
    • Icelandic
    • Indonesian
    • Irish
    • Italian
    • Japanese
    • Javanese
    • Korean
    • Latin
    • Latvian
    • Lithuanian
    • Macedonian
    • Malay
    • Malayalam
    • Maltese
    • Maori
    • Marathi
    • Mongolian
    • Nepali
    • Norwegian
    • Persian
    • Polish
    • Portuguese
    • Punjabi
    • Quechua
    • Romanian
    • Russian
    • Samoan
    • Serbian
    • Slovak
    • Slovenian
    • Spanish
    • Swahili
    • Swedish
    • Tamil
    • Tatar
    • Telugu
    • Thai
    • Tibetan
    • Tonga
    • Turkish
    • Ukrainian
    • Urdu
    • Uzbek
    • Vietnamese
    • Welsh
    • Xhosa
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  • 16
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  • 17
    -- Select Employment Status --
    • -- Select Employment Status --
    • Employed - Full Time
    • Employed - Part-Time
    • Unemployed
    • Retired
    • Student - Full Time
    • Student - Part-Time
    • Other
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