Center Quarterly Statistical Report

Center Name*

Chapter*

Phone Number*

Email*

Date*

Report Year*

Report Quarter*
Quarter 1Quarter 2Quarter 3Quarter 4Year End Totals

Hotline Calls*

Pregnancy Test Clients Visiting Center*

Practical Assistance Clients Visiting Center*

Phone Peer Counseled Only*

Email Peer Counseled Only*

PAS Peer Counseled Only*

Peer Counseling Only At Center*

Bible Study at Center*

Attend Mentoring Class*

Children Heard Bible Story*

Newspaper / Radio / TV*

Saw Sign Outside*

Previously Visited*

Friend / Relative*

School Counselor / Teacher*

Other Agency*

Internet / Web Page*

Other*

Under 15*

15-19*

20-24*

25-29*

30-34*

35-39*

40 and over*

With boyfriend*

With husband*

With children only*

With parents*

Alone*

Other*

WELS/ELS*

Protestant*

Catholic*

Muslim*

Other*

None*

Positive*

Negative*

Abortion*

Carry to term*

Undecided*

Abortion*

Carry to term*

Undecided*

God's Love (no sin & grace)*

Sin and grace*

Chastity*

Gave Bible*

Baptism*

None*

Births*

Baptisms (mother and/or child)*

Abortions*

Adoptions*

Miscarriages*

Attends WELS Church*

Attends Bible Study*

Comment*