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Client Profile

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 Full Name  

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Address  {"type":"text","name":"Address","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Date of Birth  {"type":"text","name":"DOB","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

 O
ccupation/Employer  {"type":"text","name":"Occupation","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Emergency Contact Name     {"type":"text","name":"Name2","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Emergency Phone number {"type":"text","name":"Name3","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

Relation to Client  {"type":"text","name":"RelationshipToClient","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

Relationship Status 

MarriedSingleDivorcedWidowed{"type":"select","name":"RelationshipStatus","width":100,"value":"","size":"Normal","validation":"N1","validationMessage":"Please fill in this item.","options":"\nMarried\nSingle\nDivorced\nWidowed"}


Spouse/Partner’s Name  {"type":"text","name":"SpousesName","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"Spouse's Name if applicable"}

Children

YesNo{"type":"select","name":"Children","width":100,"value":"","size":"Normal","validation":"N1","validationMessage":"Please fill in this item.","options":"\nYes\nNo"}

 

Names and Ages{"type":"textarea","name":"NameAges","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Name/Ages"}

 

Any additional information about your life you are willing to share, BE BRAVE! 

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 Preferred method of contact email or text message?

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