Demographics

Demographics
Name*

First NameLast Name
Nickname
Date of Birth*

MonthDayYear
Sex*
Gender
Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race*

WhiteBlack/African AmericanAsianMultiracialDecline to answerAmerican Indian/Alaskan NativeNative Hawaiian/Other Pacific IslanderOther
Ethnicity:*

Hispanic/LatinoNot Hispanic/LatinoDecline to answer
Language*

EnglishHmongSpanishOther
Education Level:*

Less than high schoolHigh schoolSome collegeBachelor's degree and higher
Martial Status*

MarriedDivorcedSingleLife partnerWidowedSeparated
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
MHCS contacts clients to confirm appointments. Only list a phone number where we can leave a message. Please check your appointment confirmation preference:*

Cell phoneHome phoneText messageEmailNo appointment confirmation
If you live in a residential facility, please enter the information below. If not applicable, please skip to the next section.
Residential/Group Home/Agency Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact Name*
Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship to Client*
Effective Living Center patient?

Yes
Should be Empty: