Counselling Pilot Eligibility Form

"*" indicates required fields

Personal Information

Your Name*
MM slash DD slash YYYY
What is your gender?
Are you a person with trans experience (meaning your gender identity does not align with your sex assigned at birth)?
Is it OK to leave voicemail on the phone number above?*

Financial Situation

Have you earned more than 50% of your income from the entertainment industry in 3 of the last 4 years?*
Has your entertainment industry income been at least $24K total in 3 of the last 4 years?*
5. If you have a partner/spouse, are they able to contribute financially to counselling costs?*

Supporting Documents

Drop files here or
Max. file size: 5 MB.
    Please obscure any personal information from the screenshots, if possible.
    Drop files here or
    Max. file size: 5 MB.
      We 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.