Name/Gender Marker Intake

By what name does the client prefer to be called?

First NameMiddle NameLast NameSuffix
Pronouns:
Other:
Gender identity:
Other:
Please select any of the following services needed:

Other
Current Legal Name(s)
What is the client's current legal name?

First NameMiddle NameLast NameSuffix
If the client has changed their legal name previously, please enter it in the space provided.

First NameMiddle NameLast NameSuffix
If the client changed their legal name a third time prior, please enter it in the space provided.

First NameMiddle NameLast NameSuffix
Information for Change of Name
Client's date of birth:
Client's residential address (no PO Boxes):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's mailing address (if different than residential address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's telephone number:

Area CodePhone Number
By what name does the client preferred to be called if we need to call them for any reason?

First NameLast Name
What is the client's email address?
What is the client's sex ascribed at birth:

Other
In which country was the client born?
In which city/county was the client born?
In which state was the client born?
If the client is a naturalized United States citizen, or if they are a United States citizen and were born abroad and they have a Consular Report of Birth Abroad, provide that information in the space provided.
If the client was convicted of a felony, provide the details of their felony criminal conviction(s) in the space provided.
If the client is currently incarcerated, provide the facility name and location in the space provided.
If incarcerated, provide the name(s) of the court(s) where they were convicted in the space provided.
If the client is a probationer, indicate the name of the court in the space provided.
If the client is required to register, indicate the court(s) where the conviction occurred that resulted in the requirement for them to register in the space provided.
Information about the client's parents:
For Parent 1: Enter the complete legal name of the client's first parent in the space provided.

First NameMiddle NameLast NameSuffix
Parent 1: Maiden Name (if applicable)

First NameMiddle NameLast NameSuffix
For Parent 2: Enter the complete legal name of the client's second parent in the space provided.

First NameMiddle NameLast NameSuffix
Parent 2: Maiden Name (if applicable)

First NameMiddle NameLast NameSuffix
If the client is a minor, are both parents in agreement about the minor's legal name change and/or gender marker change?
Parent 1: Provide the complete residential address for Parent 1 in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2: Provide the complete residential address for Parent 2 in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Include any additional information in the space provided.
Should be Empty:

Current Legal Name(s)

Information for Change of Name

Information about the client's parents: