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Liz Cohen Counseling
Intake And Demographic Packet
PAGE 1 of 6Name (First, MI, Last):Date:Date of Birth:
Gender:Primary Language:
Millrace:FemaleTransgenderAfrican American
Hispanic American Indian
Multiracial
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What is form influence of race?
Form Influence of Race is a form used to report race-related data and statistics.
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Organizations and institutions collecting race-related data are required to file Form Influence of Race.
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The purpose of Form Influence of Race is to track and analyze race-related data for research and policy purposes.
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Information such as race demographics, race-based outcomes, and any other relevant race-related data must be reported on Form Influence of Race.
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