Christian Life Resources

But the Lord is faithful, and he will strengthen and protect you from the evil one. - 2 Thessalonians 3:3

	Basic Information
Center Name:
Chapter:
Contact Person:
Phone:
E-mail:	Please send me an email notification of receipt
Date:
Report Year:	Quarter 1 Quarter 2 Quarter 3 Quarter 4 Year End Totals
	Activity Information
	Hotline Calls Pregnancy Test Clients Visiting Center Practical Assistance Clients Visiting Center Phone Counseled Only Email Counseled Only PAS Counseled Only
	Referral Information (referred by)
	Yellow Pages Newspaper / Radio / TV Saw sign outside Previously visited Friend / Relative School Counselor / Teacher Other Agency Internet / Web Page Other
	Age of Clients
	Under 15 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 and Over
	Living Arrangements
	With boyfriend With husband With parents Alone Other
	Religion
	WELS / ELS Protestant Catholic Muslim Other None
	Test Results
	Positive Negative
	Intentions Regarding Pregnancy
	Before Counseling: Abortion Carry to Term Undecided After Counseling: Abortion Carry to Term Undecided
	Christian Witness Given
	God's Love (no sin & grace) Sin and Grace Chastity Gave Bible Baptism None
	Known Results
	Births Baptisms (mother and/or child) Abortions Adoptions Attends WELS Church Miscarriages Attends Bible Study
	Comments

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