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MsHec3 Client Application Form
Please complete the information below and one of our practitioners will contact you shortly.
*All question are strictly confidential and used only for statistical information needed for grant funding.
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* Indicates required question
Email
*
Your email
Date
*
Choose
Option 1
First Name
*
Your answer
Last Name
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Do you reside in Yavapai County?
Yes
No
Other:
Clear selection
Total Household income
*
Your answer
Other Income (Child Support/Alimony etc.)
*
Your answer
Number of Dependents
*
1
2
3
4
5
Other:
Age
*
Your answer
Gender: How do you identify?
*This question is strictly confidential and used only for statistical information needed for grant funding.
*
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond
Other:
Which race or ethnicity best describes you? (Please choose only one.)
*This question is strictly confidential and used only for statistical information needed for grant funding.
Native American or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic or Latino
White / Caucasian
Multiracial or Biracial
Other:
Clear selection
Employed
Yes
No
Clear selection
Name of Employer
Your answer
Military Status
Yes
No
Clear selection
Retired
Yes
No
Clear selection
On Disability
*
Yes
No
Prefer not to answer
Are you looking for assistance with: (check all that apply)
*
Physical Health
Emotional Health
Mental Health
Spiritual Health
Education
Classes
Workshops
Required
Reason for Services?
*
Your answer
What practitioners and/or classes would you like to work with?
Your answer
DISCLAIMER: WE DO NOT TAKE THE PLACE OF A PHYSICIAN. WE RESERVE THE RIGHT
TO REFUSE SERVICES TO ANYONE AND MAY ALSO RECOMMEND AN OUTSIDE PHYSICIAN/DOCTOR.
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