UPWARD

CALL/SHEPHERD

’

S

TOUCH

COUNSELING

SERVICES

ADULT

REGISTRATION

FORM

DATE:

_________________

CLIENT NAME:_____________________________________________________________ AGE:______________

Last

First

SPOUSE/PARTNER’S NAME:__________________________________________________ AGE:______________

ADDRESS:______________________________________________________________________________________

Street

City

State Zip Code

EMAIL:__________________________________________________________________________________________

May we use this to send agency news (i.e. newsletters, etc.)? Yes No

Phones: H____________________________ W____________________________ C____________________________

OK to Call? Home: Yes No

Work: Yes No

Cell? Yes No

Spouse: H____________________________ W____________________________ C____________________________

OK to Call? Home: Yes No

Work: Yes No

Cell? Yes No

Please circle the number we should call to confirm your appointments.

Client’s Occupation/Employer: _______________________________________________________________________

Spouse’s Occupation/Employer: _______________________________________________________________________

Do you have insurance? Y N Company: ____________________________________________________________

Client’s Date of Birth: ________________ Spouse’s Date of Birth: ________________

MARITAL STATUS:

_____ Single

_____ Married How long? _________________

_____ Divorced How long? _________________

_____ Separated How long? __________________

_____ Remarried How long? __________________

_____ Widowed How long? __________________

Please list names of children:

Age:

Grade:

Lives with You?:

________________________________________________

_______ _______

YES NO

MARRIED SINGLE

________________________________________________

_______ _______

YES NO

MARRIED SINGLE

________________________________________________

_______ _______

YES NO

MARRIED SINGLE

________________________________________________

_______ _______

YES NO

MARRIED SINGLE

________________________________________________

_______ _______

YES NO

MARRIED SINGLE

Are you a born again Christian? Yes No Spouse? Yes No

Do you attend church regularly? Yes No Spouse? Yes No If so, where? ___________________________________

Are you a member? Yes No Pastor’s Name: _______________________________________________________

Have you had previous counseling? Yes No Where? ________________________________________________

Has your spouse/partner? Yes No Where? ________________________________________________