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Client Registration
 
To see a Hopewell counselor complete the following steps.  If you are not yet sure that you want to see a counselor but want to learn more about Hopewell then please use the Contact Us page. 
 
  Download and print Hopewell's registration packet: 

 Hopewell Registration Packet.pdf

Please review these documents carefully.  Each person who attends counseling sessions must sign these forms.  Your counselor will review these forms with you at the beginning of your first session.
 
  Decide if you want a specific counselor assigned to your case.  If you do, then please indicate the counselor's name in the "Counselor Preferences" field at the end of the form. 
 
  Complete the registration form below.  Required information is denoted by a red asterisk next to the field description.  The information you enter below is stored in our company database and is kept private and confidential.
 
Full Name *
First and Last Name
Counselor Preferences
For example: a specific person, gender or race
Referral
How did you hear about us?
Address
Full home address
Age *
How old are you?
Occupation *
What do you do for a living?
Gender

Ethnicity
What ethnic group do you identify yourself with?
Education
What level of education have you either completed or are you presently enrolled in?
Cell Phone
Cell Phone Number
Home Phone
Home Phone Number
Work Phone
Work Phone Number
Other Phone
Alternative Phone Number
Message?
Which phone number may the counselor leave a message?
Email
Email address we can contact you at.
Problem
Why are you seeking counseling?
Family Members
Name, Age, Gender, Relationship to you.
Marital Status and History
What is your marital status and history?
Physician's Care?
Are you under a physician's care for a specific illness?
Physician
Name of physican if under care.
Nature of Illness
If under a physician's care, what is the nature of your illness?
Medication?
Are you currently taking medication?
List Medications
If taking medications, please list names and dosages.
Previous Counseling
Have you previously participated in counseling?
Counseling Details
Dates, Location, Reason
Household Income *