MHAM – Pro Bono

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Pro Bono Counseling Project Application

In order to qualify for the Pro Bono Counseling Project services, you must apply by filling out the application below.

Learn More About the PBCP Program

First Name:
Last Name:
Today's Date
MM slash DD slash YYYY
Preferred Pronoun (optional)
Who is filling out this application?
- I am filling it out for myself.
- I am filling it out on someone else's behalf.
I am interested in receiving Peer Support
- Yes
- No
- Maybe
Email:
Date of birth:
MM slash DD slash YYYY
Phone:
Please enter your 10-digit phone number without the country code (e.g., 123-456-7890). Do not include a leading '1'.
Address
Street Address Address Line 2 City State ZIP Code
What is your preferred language?
How did you hear about the Pro Bono Counseling Project?
What is your employment status?
- Work Full Time
- Work Part Time
- Unemployed
- Caregiver of a child or family member
- Other
How many people are you financially responsible for?
Does someone else in the home assist financially with household costs?
- Yes
- No
Choose the one that best fits your situation:
- I have insurance through my employer
- I have Medicaid
- I don’t have insurance
- I have insurance through the Affordable Care Act
- I have Medicare
I have enough money to pay my household bills.
- Strongly agree
- Agree
- Neutral
- Disagree
- Strongly Disagree
I have enough money to afford the kind of clothes I need.
- Strongly agree
- Agree
- Neutral
- Disagree
- Strongly Disagree
I have enough money to pay my medical bills.
- Strongly agree
- Agree
- Neutral
- Disagree
- Strongly Disagree
I have enough money to afford leisure/ fun activities.
- Strongly agree
- Agree
- Neutral
- Disagree
- Strongly Disagree
I have enough money to afford the kind of food I need.
- Strongly agree
- Agree
- Neutral
- Disagree
- Strongly Disagree
At the end of the month, I have enough money to pay my bills.
- Strongly agree
- Agree
- Neutral
- Disagree
- Strongly Disagree
Are you pregnant or have you been pregnant in the past 12 months?
- Yes
- No
- Not applicable
Please tell us a little about what issues are going on in your life that are bringing you to therapy
- Difficulty coping
- Relationship difficulties
- Grief/ loss
- Life transition
- Problems at Work
- Problems at School
- Medical/ sickness
- Financial stress
- Family issues
- Mental Illness
- Addictions
- Other:
Please explain:
Have you received counseling in the past? If so how long ago?
How many days in the past 30 days would you say your mental health was not good (difficulty coping)?
Please enter a number from 0 to 30.
How many trusted adults do you have in your life who you can talk to about your mental health?
- 0
- 1
- 2 or more
Please tell us what improvements you would like to make in your life through the help of the Pro Bono Counseling Project?

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