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Intake Form Wellness Services SECTION I IDENTIFYING INFORMATION Name Today s Date Address City State Zip Student ID Date of Birth / / Age What do you prefer to be called Home phone Cell phone May we leave a message Y N May we email you WTCC email Ethnic Background African American International Sexual Orientation Heterosexual Asian White Hispanic Native American Multiracial Other Lesbian Gay Other Marital Status Single Married Separated Bisexual Questioning Prefer not to answer Divorced...
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