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Mailing Address: PO Box 1532, Clarksburg MD 20871
We are happy you are here! Let us know how we can help.
I am...
an individual
representing an organization
What are you looking for?
I need help
I want to help
I’m interested in...
Clinical support from a licensed mental health professional
Peer Support Group
Education and training
I'm interested in becoming a...
Wellness Ambassador
Provider - Licensed MHP (including interns, provisional, and graduate) and Alternative Providers
Trained Peer Supporter
Partner
Organization Information
Name of Organization
Address 1
Address 2
City
State
Please select...
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Contact Information
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XXX-XXX-XXXX
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My address differs from that of my business.
Address 1
Address 2
City
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Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
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How did you hear about Give an Hour?
Please select...
Social Media (e.g.: Facebook, Instagram, X)
Personal Recommendations (e.g.: friend, family member, colleague)
Healthcare Providers (e.g.: therapist, doctor)
Online Web Search (e.g.: Google, Bing)
Educational Institutions
Community and Military Organizations
Media
Events and Conferences
Other
How did you hear about Give an Hour?
Please select...
Professional Networks and Conferences
Give an Hour Partnerships and Referrals
Media and Publications
Social Media and/or Online Search
Government and Military Associations
Educational Institutions or Collaborations
Community Outreach and Events
Direct Contact by Give an Hour
Other
If Other, please let us know how you heard about us below.
Indicate all lived experiences you or your loved one has connection to:
Military Service
Rare Disease
Mass Violence
Interpersonal Violence
Financial Fraud
Other
If Other, let us know your experience of concern that brought you here today:
We're interested in...
Collaborating and partnership
Receiving education and training
Enrolling as a group mental health practice
Select all that apply
Birthdate
Gender
Please select...
Man
Woman
Genderqueer (transgender, non-binary, gender fluid, genderless, genderfree, gender nonconforming)
Any identity not listed here (specify)
Prefer not to say
Specify Gender
Race/Ethnicity
Please select...
America Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino/a/x
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Prefer not to say
Specify Race/Ethnicity
Insurance Status
Please select...
I have insurance I can use
I have insurance but need probono care
I do not have insurance, but can pay sliding scale
I do not have insurance and need probono care
Insurance Carrier
Select "Other" if none of the options above apply.
If Other, please specify:
Type of counseling requested
Individual
Couples
Current Concerns
Depression
Anxiety
Relationship
Substance Use
Financial
Life Transition
Trauma/Post Traumatic Stress
1
2
3
4
5
Rate the difficulty you have experienced in accessing mental health care services
. (1 was very easy. 5 was very difficult.)
Service Member or Veteran
Role
Please select...
Service Member
Veteran
Military Spouse
Family Member
Military Contractor
Branch Affiliation
Please select...
Air Force
Air National Guard
Air Reserve
Army
Army National Guard
Army Reserve
Coast Guard
Coast Guard Reserve
Marine
Marine Reserve
Navy
Navy Reserve
Rare Disease
Role
Please select...
Rare Caregiver
Loved one of a Rare Caregiver
Person with Rare Disease
What Rare Disease are you or your family affected by?
Interpersonal Violence
Role
Please select...
Survivor
Loved one of a survivor
What type of interpersonal violence have you experienced:
Please select...
Family violence
Dating and/or intimate partner violence
Assault by a stranger
Human trafficking
Other, please specify
Please Specify:
When did the
event
first occur
?
Financial Fraud
Role
Please select...
Survivor
Loved One of a survivor
Reason for request (
Briefly describe what type of financial fraud experienced. Please give as much detail as you are comfortable with
.)
When did the crime
or event
first occur
?
Mass Violence
Role
Please select...
Survivor
Loved One of a survivor
What mass violence event were you affected by?
Organization Type:
Please select...
Non-profit
Government Agency
Small Business
Mid-size / Large Corporation
Education Institution
Who is the intended audience for the training?
Please select...
Organization Employees – Staff members of all levels
Peer Support facilitators – Individuals currently facilitating or plan to facilitate peer support groups
Mental Health Providers – Licensed or aspiring mental health professionals
New to Peer Support – Individuals interested in learning the basics of becoming an effective peer supporter
Other, please specify
Please Specify:
What community does your organization currently serve?
Please select...
Military
Rare Disease
Crime and Violence
Workforce
Aging
Human Services
Other, please specify
Please Specify:
Type of Partnership:
Please select...
Just Curious - My organization is aligned with Give an Hour's mission and I would like to learn more about your work.
Share Resources - My organization serves populations in need of mental health support and I want to refer them to Give an Hour.
Give Back - I have an amazing story to tell that could uplift Give an Hour clients on their mental health journeys.
Make Connections - Both of our organizations could benefit from sharing networks; let's connect and make some valuable introductions.
Let's Collaborate - My team has great ideas and wants to work alongside Give an Hour to bring them to life!
Contribute - I want to offer my learning content, write a blog post, provide an article, or share research with Give an Hour's audiences.
Sponsorship - My organization wants to support Give an Hour's work through funding and event participation.
Advertising - My organization would like to purchase ad space on a Give an Hour platform (website, social media, newsletter, etc.)
Are there any other details you'd like to share with us?
Partnership Tim
e
line:
Please select...
Immediately - let's get started now!
3 - 6 Months - prepared to begin in the near future
6 - 12 Months - making plans for down the road
12+ Months - considering possibilities for "someday"
Ongoing - this would be a strategic and lasting partnership
I have an event date in mind:
Yes
No
Enter Event Date:
By submitting this form, you agree to all Give an Hour’s terms and conditions.
Yes
No
By submitting this form, you agree to all Give an Hour’s terms and conditions.
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