SHEPHERD’S TOUCH COUNSELING MINISTRY – YOUTH REGISTRATION FORM

UPWARD CALL/SHEPHERD’S TOUCH COUNSELING SERVICES

YOUTH REGISTRATION FORM

DATE: _______________________

CLIENT NAME: ____________________________________________________________________________________________

Last First

ADDRESS: _________________________________________________________________________________________________

Street City State Zip Code

Parents / Step-Parents / Guardians with whom you live:

___________________________________________________________________________________________________________

Last First

Do you have a parent who does not live with you? Yes No If Yes, list name & address:

___________________________________________________________________________________________________________ Last First

ADDRESS: _________________________________________________________________________________________________

Street City State Zip Code

Phones: H____________________________ W____________________________ C____________________________

Parents: H____________________________ W____________________________ C____________________________

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

Client’s Age: ___________ Client’s Date of Birth: ____________________________________

Client’s Grade Level: _________ School Attending: ________________________________________

Parent’s MARITAL STATUS:

SIBLINGS: Age: Grade: Lives with You?: Married / Single:

______________________ ________ _______ _______________ ___________________________________

Are you a born again Christian? Yes No Do you attend church regularly? Yes No

If so, where? ________________________________________________________________________________________________

Have you had previous counseling? Yes No Where? ___________________________________________________________

Do you have insurance? Yes No Company: _______________ Name and DOB of Policy Holder ________________________