Apply For ServicesTake a few minutes and fill out our application to apply for services with Bridging Hope. 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 Date Of Birth * MM DD YYYY Email * 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: 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? 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? Yes No If yes, please describe. Thank you for your application. Someone from our team will reach out soon!
