Date
MM
DD
YYYY
Name of Individual Seeking Counseling
*
First Name
Last Name
Name of Parent/Guardian if client is under 18 years of age
*
First Name
Last Name
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Age of person seeking counseling?
Gender of person seeking counseling?
*
Male
Female
Please select your annual household gross income:
$0-$40,000
$40,001-$50,000
$50,001-$60,000
$60,001-$70,000
$70,000 & above
Please select your family size:
1
2
3
4
5 or more
Please briefly describe your reason for counseling:
Counseling fees through Bridging Hope are $20 per 55-minute session. If this would be a financial hardship for you, please describe the financial hardship you are experiencing which you would like to be considered in our review of your application. You may be required to provide proof of any item listed.
Please describe your living situation (where you live, who you live with):
Currently, is there any domestic violence in the home?
If yes, please briefly describe:
Are you actively using any substances (alcohol, marajuana, or any others)?
If yes, please state what substance(s):
How much do you use and how often do you use?
Have you had any thoughts of harming yourself or others in the past 7 days?
If yes, please describe.
