Personal Information
	First Name:
	Middle Initial:
	Last Name:
	Social Security Number:	- -
	Date of Birth (MM-DD-YYYY):	< April 2024 > S M T W T F S   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Will this counseling session be individual or joint? single joint?
First Name: Middle Initial: Last Name: Social Security Number: - - Date of Birth (MM-DD-YYYY):
	Address:		Apt or Suite No.
	Zip Code:
	City:
	State:
	Home Phone Number:	() -
	Work Phone Number:	() -	Ext:
	Cell Phone Number:	() -
	Fax Number:	() -
	Email Address:
Login Information
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	Password:	Password should be between 6 and 20 characters.
	Confirm Password:
Demographics
	Number of Adults
	Number of Children
	Marital Status:	--Please Select -- Choose not to respond Divorced Married Other Separated Single Widowed
		Client	Co-client
	Gender:	-- Please Select -- Male Female Decline to Answer	-- Please Select -- Male Female Decline to Answer
	Education:	--Please Select -- Associates Bachelors High School/GED Masters Decline to Answer No academic credentials Some College	--Please Select -- Associates Bachelors High School/GED Masters Decline to Answer No academic credentials Some College
	Race:	--Please Select -- African-American Amer/Alaska Native Amer/Alaska&White Amer/Alsk Native&Blk Asian and White Asian-American Black and White Choose not to respond Hawaiian-Pacific Isl Other Multiple Race White/Latin	--Please Select -- African-American Amer/Alaska Native Amer/Alaska&White Amer/Alsk Native&Blk Asian and White Asian-American Black and White Choose not to respond Hawaiian-Pacific Isl Other Multiple Race White/Latin
	Ethnicity:	--Please Select -- Hispanic Not Hispanic Choose not to respond	--Please Select -- Hispanic Not Hispanic Choose not to respond