TRANSFORM 2025 Application Form

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you able to commit to bi-weekly 90-minute sessions (counselling & workshops) from October 2025 through June 2026? *

Yes

No

I am not sure.

Are you currently employed? *

Yes, full-time

Yes, part-time

Not employed.

What is your highest level of formal education? *

High School Diploma/GED

Technical Certificate

Associates Degree

Undergraduate Degree

Post-Graduate Degree

Other

None of the above.

Have you ever had counselling before? *

Yes

No

To help us provide the best support, please let us know if there are any mental health challenges or cognitive/learning differences that you feel are important for us to be aware of. *

Yes

No

Have you ever had challenges with substance use that you feel may impact your participation? *

Yes

No

Nationality *

Bermudian

Spouse of a Bermudian

Non-Bermudian

Marital Status *

Check all that apply

Married

Single

Separated

Divorced

Widowed

Re-Married

Income *

$0 - $40,000

$41,000 - $60,000

$61,000 - $80,000

$80,000+

Referred by *

Self

Police

Medical/Doctor

Friend/Family

Other

Today's date *

MM

DD

YYYY