Adult Registration Form - Shepherd's Touch Counseling Ministry

SHEPHERD’S TOUCH COUNSELING MINISTRY – ADULT REGISTRATION FORM

DATE: ___________________

CLIENT NAME:

Last First Spouse’s

ADDRESS:

Street City State Zip Code

EMAIL:

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? Yes No Company:

Client’s Age: _________ Spouse’s Age: _________ Approximate Family Income:

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? Married / Single?

Yes No M S

Are you a born-again Christian? Yes No Your spouse? Yes No

Do you attend church regularly? Yes No Your 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? Yes No Where?