* Required Field

ABOUT ME:
First Name:*
Last Name:*
I am a/an:*
Birth Date:*
Gender:*
 

Race:*
Ethnicity: Hispanic
Primary Language:* English  Spanish
ASL      Other
Disabilities: Hearing impaired
Mobility impaired
Sight impaired  
Veteran status: I am a Veteran
Size of household: (required for Hamilton Co.)
Number of Children:
Estimated yearly income: (required for Hamilton Co.)
I need the counseling location to be on a bus line

CONTACT INFORMATION:
E-mail Address:*
Home Phone:* ok to leave message
Cell Phone: ok to leave message

ADDRESS:
Street Address:*
Address (Line 2):
City, State  ZIP:* ,  
County:*

ABOUT MY NEEDS:
I am interested in:
 
I am an immigrant or refugee:
  Yes   No

I am available for counseling:
*
  morning
afternoon
evening
weekend

I have used the Pro Bono Counseling Program before:
  Yes   No

I heard about the Pro Bono Counseling Program from:


The primary concern I would like to talk about in counseling is:
*
Anxiety
Depression
Postpartum depression
Anger management
Life stress
Domestic violence
Eating disorders
Long-term physical illness
Marital/Partner counseling
Sexual abuse
Physical abuse
PTSD
Sexuality
Gender issues
Grief
Spiritual issues
Loss of employment
Victim of crime
Witness to crime
Family issues
Other (describe in the "Other
    Information" box below)

Do you currently have health insurance?
  Yes
  No

I would prefer a mental health professional who is:
 
Race:
Gender:

I am on the following medications:
  Anti-depressant
Anti-psychotic
Anti-anxiety
Mood stabilizer
Physical health medication

Other information I feel would be important to know about me:


Are you completing this form on behalf of the client?  If so, please include your name and relationship to the client in the text area above.
 
Verification Word:  To help us reduce fraudulent submissions, please type the word shown below into the box provided:

(lowercase or uppercase)

By clicking the "Submit Application >" button below, I understand that the information I submit will be used by the Pro Bono Counseling Program to match me with the most appropriate mental health professional based on my problem and other factors. Certain information may be given to this professional so that they have basic information about your situation.