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an individualrepresenting 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 professionalPeer Support GroupEducation and training

I'm interested in becoming a...

Wellness AmbassadorProvider - Licensed MHP (including interns, provisional, and graduate) and Alternative ProvidersTrained Peer SupporterPartner

Organization Information

Name of Organization

Address 1

Address 2

City

State

Zip Code

Website

Contact Information

First Name

Last Name

Mobile Phone Number

XXX-XXX-XXXX

Title

My address differs from that of my business.

Address 1

Address 2

City

State

Zip/Postal Code

How did you hear about Give an Hour?

If Other, please let us know how you heard about us below.

Indicate all lived experiences you or your loved one has connection to:

We're interested in...

Collaborating and partnership Receiving education and training Enrolling as a group mental health practice Select all that apply

Birthdate

Gender

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Race/Ethnicity

Specify Race/Ethnicity

Insurance Status

Insurance Carrier

Select "Other" if none of the options above apply.

If Other, please specify:

Type of counseling requested

IndividualCouplesFamily

Service Member or Veteran

Role

Branch Affiliation

What is your relationship to your military or veteran family member? (mother, father, son, daughter, etc.)

Reason for seeking support at this time

Rare Disease

Role

Patient Advocacy Group(s) connected to

What Rare Disease are you or your family affected by?

Reason for seeking support at this time

Interpersonal Violence

Role

What type of interpersonal violence have you experienced:

Reason for request (Briefly describe your Interpersonal Violence experience. Please give as much detail as you are comfortable with.

When did the event first occur?

Financial Fraud

Role

Type of Fraud that best describes your experience

Reason for request (Briefly describe what type of financial fraud experienced. Please give as much detail as you are comfortable with.)

When did the fraud first occur?

Organization Type:

Estimated # of Employees at the Organization

Estimated # of Military Veteran Employees at the Organization

Estimated # of Formerly Incarcerated Employees at the Organization

Estimated # of Volunteers at the Organization

Who is the intended audience for the training?

Please Specify:

Type of Partnership:

Are there any other details you'd like to share with us?

Partnership Timeline:

I have an event date in mind:

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Enter Event Date:

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