← Back to All Forms TRANSFORM 2024 Application FormCLIENT INFORMATIONThis application form must be completed in full for consideration for the WRC TRANSFORM Programme*Note: Submitting an application does not guarantee placement in the next TRANSFORM cohort. Applications will be reviewed and each applicant will be notified of the outcome by May 25th 2024. The next TRANSFORM Cohort begins in June 2024. Name * First Name Last Name Date of birth * MM DD YYYY Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you currently employed? * Yes, full-time Yes, part-time Not employed. What is your highest level of formal education? * High School Diploma/GED Associates Degree Graduate Degree Post-Graduate Degree Other None of the above. If you selected 'other', please explain: * Have you ever had counselling before? * Yes No If yes, when was the last time you were engaged in counselling/therapy services. Are there any specific things you would like to achieve through counselling? Are you able to commit to bi-weekly 90-minute sessions (counselling & workshops) fromJune 2024 through February 2025? * Yes No I am not sure. If yes, please describe and list any medications: Do you have a history of drug or alcohol abuse? * Yes No In a few words, please explain why you are interested in the TRANSFORM programme? * If you are accepted into this cohort of TRANSFORM, how do you think it will benefit your life? * STATISTICAL INFORMATION BELOW Age * Race * Black White Asian Mixed Other Nationality * Bermudian Spouse of a Bermudian Non-Bermudian Marital Status * Check all that apply Married Single Separated Divorced Widowed Re-Married Number of dependant children * Ages of dependant children * Separate ages with a comma Income * $0 - $40,000 $41,000 - $60,000 $61,000 - $80,000 $80,000+ Level of education * Primary School Secondary School/GED Associates Undergraduate Postgraduate Doctorate Referred by * Self Police Medical/Doctor Friend/Family Other If response is 'Other' to the question above - Please specify Today's date * MM DD YYYY Please provide your initials to confirm the information provided is correct. * Thank you for submitting the Counselling Intake Form.
