This information you provide will remain confidential.
Please tell us about yourself:

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* 1. Preferred Name/ Pronouns

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* 2. Date of Birth

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* 3. Phone

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* 4. Home Address

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* 5. Email Address

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* 6. Personal identifier: First three letters of the city you were born (i.e. Bakersfield is “BAK”)

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* 7. The day of the month you were born (i.e. February 1st is “01”)

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* 8. The first two letters of the street you grew up on (i.e. Mohawk is “MO”)

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* 9. The first three letters of of the first school you attended (i.e. if you went to Westfield Elementary it would be WES; if you were homeschooled you would enter HOM

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* 10. Age Group:

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* 11. Gender assigned at birth:

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* 12. Current gender identity:

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* 13. Sexual orientation:

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* 14. Primary Language:

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* 15. Disabilities:

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* 16. Veteran Status:

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* 17. Race:

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* 18. Ethnicity:

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* 19. Do you currently have health insurance? If yes, who is your insurance company?

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* 20. What are your present mental health symptoms? How long have you experienced these present symptoms?

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* 21. Have you had any counseling /therapy previously? Where did you receive counseling/therapy? Who was your provider?

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* 22. Have you experienced any trauma in the past (sexual assault, abuse, death of a friend or relative, car accident, bullying, etc)? If you are comfortable, please explain below.

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* 23. What are your counseling goals?

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* 24. Does your family have a history of mental health concerns?

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* 25. Who are your primary social supports?

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* 26. What are your strengths?

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