Advisory Committee Quarterly Report Company Year Quarter QTR 1QTR 2QTR 3QTR 4 MO 1 MO 2 MO 3 TOTAL Calls to Hotline Calls to Hotline month 1 Calls to Hotline Month 2 Calls to Hotline month 3 Total Total: In-depth Abortion counseling Abortion Counseling Mo 1 Abortion Counseling Mo 2 Abortion Counseling Mo 3 Total Total: New Adult Clients (In Office for First time) New Adult Clients Mo 1 New Adult Clients Mo 2 New Adult Clients Mo 3 Total Total: Counseling Sessions Counseling Sessions Mo 1 Counseling Sessions Mo 2 Counseling Sessions Mo 3 Total Total: Post-Abortive Counseling Post-Abortive Counseling Mo 1 Post-Abortive Counseling Mo 2 Post-Abortive Counseling Mo 3 Total Total: Adoption Referrals/Placements Adoption Referrals Mo 1 Adoption Referrals Mo 2 Adoption Referrals Mo 3 Total Total: Pregnancy Tests Pregnancy Tests Mo 1 Pregnancy Tests Mo 2 Pregnancy Tests Mo 3 Total Total: Positive Tests Positive Tests Mo 1 Positive Tests Mo 2 Positive Tests Mo 3 Total Total: Negative Tests Negative Tests Mo 1 Negative Tests Mo 2 Negative Tests Mo 3 Total Total: Totals Total Total: Total Total: Total Total: Total Total: Do you counsel with every pregnancy test given? YesNo Relevant Comments Name of Reporting Agency * Address to Mail Check: Agency Code Attention Mailing Address * Phone Number * Total Hours Open per week Alternative Phone if available Email Address * I agree that the information provided is true and accurate. Privacy Policy * We promote on our Website YesNo We promote on our Facebook YesNo We promote on our Newsletter YesNo We promote at our Annual Fundraiser YesNo We include CL on our Website YesNo We include CL on our Facebook YesNo We include CL in our Newsletter YesNo We include CL in our Annual Fundraiser YesNo
