HIC Trauma & Cultural Counseling Services Enrollment Form
Please complete all items. Please ask a counselor for assistance if you have any questions about an item. Thank you!
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First Name *
Last Name *
Preferred Name *
Date of Birth *
MM
/
DD
/
YYYY
Email *
How did you find out about HIC Counseling Services? *
Required
If you were referred by an agency, please provide the name of the agency.
Gender *
Race *
Are you Hispanic or Latino? *
Country of Origin *
Primary Language *
Employment Status *
How many jobs do you have? *
Required
What is your current living arrangement? *
Do you deal with food insecurity? *
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