CHFS Registration Form

CHFS Registration Form

Please Note: In order for your application to be considered, all required fields must be fully completed.
First Name*
Middle Initial (optional)
Last Name*
Date of Birth*

MonthDayYear
Date
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own or rent your home?
Phone Number*
Gender
Marital Status

SingleMarriedWidow
Race
Primary Language*
Education
Highest Grade Completed*
High School Graduation Date

MonthDayYear
Date
College Graduation Date

MonthDayYear
Date
Professional Certification(if applicable)
Certification(Please specify)
Issued By
Employment
Current Employment Status*
Name of Current Employer
Start Date

MonthDayYear
Date
Hours per Week
Wages per Hour
What is the total income earned in the previous years( 12 months) as shown on your IRS tax forms: $Earned Income after Tax
This ONLY includes earned income (wages, salaries, tips, etc.). Report your actual earned income over
Select a program you are interested from the following :*
Vocational Interest
Start If unemployed (or looking for new employment), what are your interests?

Accounting / BookkeepingCarpentryConstructionCosmetologyEducationEntrepreneurshipFinancial ServicesFood ServiceHealth CareInformation TechnologyLandscapingManufacturingSTEM (Science, Technology, Engineering, Mathematics)OtherUnsure
Vocational Training History*
Military Status*
Criminal Convictions*
Household Details
Marital Status*
Household Size*
*A household is 1 or more heads of household & their dependents. This may include people who don’t live together (e.g. child at college, parent in nursing home). People living together may not be in the same household (e.g. roommates who don’t blend finances).
Household Role*
Your Gross Household Income: $
Estimate household income for past 12 months.
Only include wages/salaries/tips, business, interest/dividend, unemployment/disability, welfare assistance, alimony/child support, pension/retirement, regular gifts from non-household members & armed forces.
Are you in need of financial assistance ?

YesNo
Are you willing to receive assistance in the form of a loan ?

YesNo
Health Insurance Status (primary insurance only):

Household Members

	First Name	Middle Initial	Last Name	Birth Date (mm/dd/yyyy)	Household Role (Parent, Child, etc.)	Gender (F M T O)
1
2
3
4
5
6
7
8
9
10

Is there anything else you would like for us to know about you?
How did you hear about us?

CLIENT CONSENT FORM

Note: Please complete this consent form if you are seeking our counseling services.
COUNSELING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained counselor(not a therapist) who has the desire and willingness to help you accomplish your individual goals. Counseling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counseling, there may be periods of increased anxiety or confusion. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. Your counselor is available to support you throughout the counseling process.

CONFIDENTIALITY:

All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential.

You may contact our office in writing that the counseling staff could release specific information about your counseling to persons you designate.

EXCEPTIONS TO CONFIDENTIALITY:

Since our counseling services is a multi-disciplinary in nature, the counseling staff works as a team. Your counselor may consult with other counseling staff to provide the best possible care. These consultations are for professional and training purposes.

• If there is evidence of clear and imminent danger of harm to self and/or others, a counselor is legally required to report this information to the authorities responsible for ensuring safety.

• The State of Florida law requires that any counseling services who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age must report this information to the authority or child protective services.

• A court order, issued by a judge, may require the Counseling Services staff to release information contained in records and/or require a counselor to testify in a court hearing.

We appreciate prompt arrival for appointments. Please notify us at (850) 999-6610 if you will be late. Twenty-four hour notice of cancellation is required. This allows us to use the time for others.

I have read and discussed the above information with my counselor. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of the CHFS Counseling Services.
Signature of Client

Clear
Date

MonthDayYear
Date

CHFS Registration Form

Education

Employment

Vocational Interest

Household Details

CLIENT CONSENT FORM

Instruction