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Please Note: Our team will be participating in an organization-wide retreat from Monday, August 10, through Wednesday, August 12. During this time, Give an Hour remains operational; however, you may experience longer-than-usual response times to inquiries submitted through this form. Thank you for your patience. We look forward to connecting with you as soon as possible.

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I am...

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.

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

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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

IndividualCouples

Service Member or Veteran

Role

Branch Affiliation

Relationship type (mother, father, son, daughter, etc.)

Rare Disease

Role

What Rare Disease are you or your family affected by?

Interpersonal Violence

Role

What type of interpersonal violence have you experienced:

Please Specify:

When did the event first occur?

Financial Fraud

Role

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

What mass violence event were you affected by?

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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By submitting this form, you agree to all Give an Hour’s terms and conditions.

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