SHEPHERD’S TOUCH COUNSELING MINISTRY – 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, please 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 Grade: __________   School Attending: __________________________

PARENTS’ MARITAL STATUS:

_____   Single                                                              _____  Separated      How Long? _________                      

_____   Married       How long?  _________               _____  Remarried     How Long? _________

_____   Divorced     How long?  _________              _____  Widowed      How Long? _________

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

       Yes         No                    M            S      

       Yes         No                    M            S       

       Yes         No                    M            S      

       Yes         No                    M            S      

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: __________________________________________________