Counselling Pilot

Personal Information

Your Name*

First Last

Preferred Name*

Profession/Occupation*

Date of Birth*

What is your age?*

What is your gender?

Woman

Non-binary

Man

Are you a person with trans experience (meaning your gender identity does not align with your sex assigned at birth)?

Yes

Email*

Phone*

Is it OK to leave voicemail on the phone number above?*

Yes

Address*

Street Address Address Line 2 City Province Postal Code

Emergency Contact (Name and Phone Number)*

Financial Situation

Your 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 2022 and this year to-date, as well as the approximate balance in the corporate account

Is there any expected income in the next 30 days? If yes, please list how much and from what source

Please list approximately how much your monthly expenses are*

5. If you have a partner/spouse, are they able to contribute financially to counselling costs?*

Yes

N/A

Supporting Documents

Please upload your work history from union or resume/CV*

Drop files here or

Max. file size: 5 MB.

Please upload a screenshot of your bank balance (chequing and savings accounts)*

Please obscure any personal information from the screenshots, if possible.

Drop files here or

Max. file size: 5 MB.

Please use this field for any additional information

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.

Counselling Pilot