Demographic Sheet

Counseling & Health Services

Demographic Info
Legal Name (First, MI, Last): *
Student ID#: *
How should we greet you (preferred name)?
Pronouns:
Date of Birth *

Month Day Year
Date
Age *
Phone Number *
Hamline Email *
example00@hamline.edu
Address (where you would like us to send any mail correspondence) *

Street Address

Street Address Line 2

City State

Zip Code
Emergency Contact

Full Name Relationship Phone Number
Can Counseling & Health Services leave you a voicemail message? *

Yes No
Can Counseling & Health Services send you an email if needed? *

Yes No
Can Health Services send you appointment reminders via text message? (this option is currently not available for Counseling appointments.) *

Yes No
University Information

Check all that appy
*

Undergraduate Graduate Post Bac/other
*

Full Time Transfer Part Time Academic probation
Major/Program: *
Expected graduation semester/year: *
GPA
If you are a student athlete, list sport
If you are an international student, list home country
Personal Information:

(If you prefer not to answer a question, please fill in the field with "Decline". If a question does not apply to you, please fill in the field with "NA" or "None")
Race/ethnicity *
Religious affiliation, if any *
Sex assigned at birth *
Gender identification *
Sexual orientation *
Marital/Relationship status *
Do you live on or off campus? *

On Off Prefer not to answer
With whom do you live? *
Do you work? *

Yes No Prefer not to answer
If yes, where do you work?
How many hours per week do you work?
Are you the first person in your immediate family to attend college? *

Yes No Unsure Prefer not to answer
Should be Empty:

Counseling & Health Services

University Information

Personal Information: