Today's Date *

MM

DD

YYYY

Client Name *

Include Middle Name

First Name

Last Name

Is this your legal name?

Yes

No

Birth Date *

MM

DD

YYYY

Preferred Pronouns

He/Him

She/Her

They/Them

What is your gender?

Male

Female

Trans - female to male

Trans - male to female

Intersex

Other

Prefer not to answer

Do not know

What is your sexual orientation?

Straight, male/female relationship

Gay

Lesbian

Bisexual

2-spirit

Queer

Pansexual

Asexual

Other

Prefer not to answer

Do not know

Race/Ethnicity

Check more than one if applicable.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino/a/e

Native Hawaiian or Other Pacific Islander

White

Other

Prefer to not say

Birth Date

MM

DD

YYYY

Is this person a client here?

Yes

No

Chose clinic because/Referred to clinic by:

Dr.

Insurance Plan

Hospital

Family

Friend

Close to home/work

Yellow Pages

Other

Is this client covered by insurance?

Yes

No

Subscriber’s Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Client's relationship to subscriber:

Self

Spouse

Child

Other

Birth Date

MM

DD

YYYY

Client's relationship to subscriber:

Self

Spouse

Child

Other

Date

MM

DD

YYYY

Your Preference

St. Paul

Fridley

Faribault

Telehealth