Apply For ServicesTake a few minutes and fill out our application to apply for services with Bridging Hope. Date MM DD YYYY Name * First Name Last Name Email * Phone * (###) ### #### Date Of Birth * MM DD YYYY Gender * 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: Please list any additional financial hardship you are experiencing which you would like 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? Yes No If yes, please briefly describe: Are you actively using any substances (alcohol, marajuana, or any others)? Yes No 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. Thank you for your application. Someone from our team will reach out soon!
