Client Information Form

Preferred Name:Pronouns:Date of Birth: *Address: *City *Zip: *Primary Phone Number: *Email *Administrative Sex— Choose One —MaleFemaleChoose Not to DiscloseGender Identity:— Choose One —FemaleMaleTrans WomanTrans ManNon-BinarySomething ElseChoose Not to DiscloseChoice 10Choice 7Sexual Orientation— Choose One —AsexualBisexualLesbian or GayStraightSomething ElseChoose Not to DiscloseRace:Marital Status:— Choose One —UnmarriedMarriedDomestic PartnerPolygamousDivorcedWidowedLegally SeparatedChoose Not to DiscloseEmployment:— Choose One —Full-time, employedPart-time, employedSelf-employedContract, per diemFull-time, studentPart-time, studentActive MilitaryRetiredLeave of AbsenceUnemployedSomething ElseConsent to Better Mindset Therapy Leaving a Voice Message *— Choose One —YesNoPlease provide your availability below. If you prefer us not to leave a message when calling, please be sure to select ‘No’Availability & Additional Information:Please provide any other information you feel comfortable sharing with our admin staff at Better Mindset Therapy. Do not include any Protected Health Information. Please include your availability so we may utilize it to set up your appointment call back.
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