← Back to All Forms TRANSFORM 2024 Application FormCLIENT INFORMATIONThis application form must be completed in full for consideration for the WRC TRANSFORM Programme*Note: The next TRANSFORM Cohort begins in June 2025. Submitting an application does not guarantee placement in the next TRANSFORM cohort. Early submissions will be added to the waitlist. 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 This information will be stored securely and used for statistical data, impact reporting and applications for funding. 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. * Checkbox Option 1 Option 2 Thank you for submitting the Counselling Intake Form.
