Counseling Application Counseling Application Please complete the application to determine your eligibility for the Full of Hope Counseling Program {"Eapcode":{"display_mode":"show","fire_action":"All","file_types":"png","logic_data":[{"cfef_logic_field_id":"EAP","cfef_logic_field_is":"==","cfef_logic_compare_value":"I have an EAP","_id":"1bec44f"}]},"message":{"display_mode":"show","fire_action":"All","file_types":"png","logic_data":[{"cfef_logic_field_id":"field_353fe33","cfef_logic_field_is":"==","cfef_logic_compare_value":"Not listed (please describe below)","_id":"65b05d3"}]},"field_3b2aa3d":{"display_mode":"show","fire_action":"All","file_types":"png","logic_data":[{"cfef_logic_field_id":"field_353fe33","cfef_logic_field_is":"==","cfef_logic_compare_value":"Not listed (please describe below)","_id":"65b05d3"}]},"field_33faffd":{"display_mode":"show","fire_action":"All","file_types":"png","logic_data":[{"cfef_logic_field_id":"field_1f9c299","cfef_logic_field_is":"==","cfef_logic_compare_value":"Yes (Please list medications)","_id":"65b05d3"}]}} First Name* Last Name* Birth Date* Gender* Male Female Other Prononuns* He/Him She/Her They/Them Primary Language* English Spanish Other Contact Information Home Phone Cell Phone Best Time to Call: Morning Afternoon Evening City State ZIP Code* ABOUT MY NEEDS: I am interested in: Individual Counseling Couples Counseling Family Counseling I am available for counseling:* Morning Afternoon Evening Weekend The Primary reason I am seeking counseling is: Anxiety Depression Postpartum Depression Anger Management Life Stress (e.g. Finances, Personal / Professional relationships) School related Stress Transitional Stress Domestic Violence Long-term Physical illness Marital/Partner Counseling Sexuality/LGBTQ Gender concerns Grief Spiritual concerns Loss of employment Family issues Not listed (please describe below) Are you taking or have you taken medications to address symptoms related to your mental health? Counseling Reason Description Have you been hospitalized in the last 6 months due to mental health concerns? Yes No Are you seeking treatment for drug/alcohol use? Yes No Are you seeking a mental health assessment or treatment mandated by the court? Yes (Responding "Yes" to any of the above may result in a referral to other community counseling services) No Are you taking or have you taken medications to address symptoms related to your mental health? Yes (Please list medications) No Medications Do you currently have health insurance? Yes No I have used the Full of Hope Counseling Program before: Yes No By clicking the "Submit Application" button below, I understand that the information I submit will be used by the Full of Hope 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. Submit Application Request An Appointment