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Name
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First
Last
Phone
City and State Residence
Age group
Under 18
18 - 24
25 - 34
35 - 44
45 - 54
Over 55
What is your gender?
*
Tell us about your Caribbean background (place of birth or descent)
Have you been to therapy before?
Yes
No
Prefer not to answer
What is the highest level of education you have completed?
*
Less than a high school diploma
High school diploma or equivalent
Vocational (ex. certificate, trade)
Associate degree (AS, AA)
Bachelor's degree (ex. BA, BS)
Masters' degree (MS...)
Doctorate (phd...)
What is your current employment status?
Employed full time (40 hours + a week)
Employed part-time (less than 40 hours a week)
Unemployed
Students
Retired
Self-Employed
What is your marital status?
Single (never married)
Married
In domestic partnership
Divorced
Widowed
What is your household income?
*
Less than 10k
10k to 50k
50k to 100k
100k to 150k
150k+
Please add anything else that you would like us to know.
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