ReadyMinds - Personal Info Form

Welcome to the Program. To get started, please complete the following online surveys. The valuable information that you provide us with will enable your counselor to learn more about you.
Note: * Required Fields

My current status is a(n):*

Please choose your username and password.
Note: You will have to re-type the same password you choose here at the bottom of this page.

First Name *	MI	Last Name *

E-mail Address *

Date of Birth*
(MM/DD/YYYY)

Gender*

Ethnicity_^

Address

Home Phone: *	( )
Alternate Phone:	( )
Fax No.:	( )
State/Province:*	State is not required for international clients
Country: *


Have you previously been assigned a Special Code? If so, please enter below.
Special Code:

How did you learn about this program?*

If other, please specify:

Retype Password

_^ We request this optional information regarding gender and ethnicity/ancestry in order to ensure culturally sensitive counseling.

For customer service call: 1-888-225-8248 or e-mail: helpdesk@readyminds.com