* Required Field

ABOUT ME:
First Name:*
Last Name:*
Audience:* Adult (18-30)
Adult (31-64)
Adult (65+)
LGBTQ
Caregiver
Birth Date:*
Gender:* Male
Female
Other:
Preferred Pronouns:
 
Race:*
Ethnicity: Hispanic
Immigrant or refugee: Yes   No
Primary Language:* English  Spanish
ASL      Other
Accommodations: I am a person who is:
Deaf or hard of hearing
Blind or visually impaired
Using a wheelchair
Size of household:
Number of Children:

CONTACT INFORMATION:
Email Address:*
Home Phone:* ok to leave message
Cell Phone: ok to leave message
Best Time to Call:

ADDRESS:
Street Address:*
Address (Line 2):
City, State  ZIP:* ,  
County:*

ABOUT MY NEEDS:
I am interested in:

I am available for counseling:
*
  morning
afternoon
evening
weekend
I need the counseling location to be on a bus line

The primary concern I would like to talk about in 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
Gender concerns
Grief
Spiritual concerns
Loss of employment
Family issues
Not listed (please describe below)

Selection of any of these concerns will require additional assessment and may not be appropriate for participation in the program. Additional resources will be provided as needed.
Eating disorders
PTSD
Sexual abuse
Physical abuse
Victim of crime
Witness to crime
 
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   No
Responding "Yes" to any of the three above questions will result in a referral to other community counseling services or MHAOhio's Get Connected Program.

Are you taking or have you taken medications to address symptoms related to your mental health?:
  Yes
No

Do you currently have health insurance?
  Yes
  No

I have used the Pro Bono Counseling Program before:
  Yes   No

I heard about the Pro Bono Counseling Program from:


I would prefer a mental health professional who is:
 
Race:
Gender:
Faith-based:
 
Are you completing this form on behalf of the client?  If so, please include your name and relationship to the client in the field below.

 
Verification Word:  To help us reduce fraudulent submissions, please type the word shown below into the box provided:

(lowercase or uppercase)

By clicking the "Submit Application >" button below, I understand that the information I submit will be used by the Pro Bono 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.