Counselling Pilot Eligibility Form Please enable JavaScript in your browser to complete this form.Personal InformationYour Name *FirstLastPreferred Name *Pronouns *Profession/Occupation *Date of Birth *What is your age? *What is your gender?WomanNon-binaryManAre you a person with trans experience (meaning your gender identity does not align with your sex assigned at birth)?YesNoAre you a member of the BIPOC or 2SLGBTQIA+ community?YesNoI’d rather not sayEmail *Phone *Is it OK to leave voicemail on the phone number above? *YesNoAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEmergency Contact (Name and Phone Number) *Financial SituationHave you earned more than 50% of your income from the entertainment industry in 3 of the last 4 years? *YesNoHas your entertainment industry income been at least $24K total in 3 of the last 4 years? *YesNoYour total earnings last year (both in and out of the industry) *Your total earnings this year to-date (both in and out of the industry) *If incorporated, please list corporate earnings from last year and this year to-date, as well as the approximate balance in the corporate accountIs there any expected income in the next 30 days? If yes, please list how much and from what sourcePlease list approximately how much your monthly expenses areIf you have a partner/spouse, are they able to contribute financially to counselling costs? *YesNoN/ASupporting DocumentsPlease upload documentation of industry income from 2020-2023 – e.g. union work history (including amounts earned), T4s, or Records of Employment * Click or drag files to this area to upload. You can upload up to 5 files. Please upload a screenshot of your bank balance (chequing and savings accounts) * Click or drag files to this area to upload. You can upload up to 5 files. Please obscure any personal information from the screenshots, if possible.Please use this field for any additional informationWe respect your right to privacy. The information you have provided in this form will only be used for the purposed of the Counselling Pilot. Your personal information will not be shared, stored, or used for any other purpose.Submit
