Counseling Application
Processing your application may take up to 10 days to complete.
Personal Information
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
yourname@me.com
Due to confidentiality, what is the best way to contact you?
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
*
Please Select
Home
Cell
Work
Preferred Method of Contact
Phone Call
Text
E-Mail
Household Members
Are there other adults living in your household?
Yes
No
Other adults living in household (include spouse, roommate, boyfriend/girlfriend, adult children, relative, friends, etc.)
*
Insurance
Are you currently employed?
Yes
No
Employer
Do you have medical insurance?
Yes
No
Insurance Provider
Does your provider offer mental health coverage?
Yes
No
Are you able to contribute to counseling costs at this time?
Partial payment
Nothing at this time
References
Please list 2 people at CTK, staff or regular attendees who canverify your need. Include phone number(s).
*
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Credit Cards, Loans, & Other Debt
Debt Worksheet
Rows
Debt Type
Monthly Payment
Balance Owed
Debt #1
Credit Card
Loan
Misc. Debt.
Debt #2
Credit Card
Loan
Misc. Debt.
Debt #3
Credit Card
Loan
Misc. Debt.
Debt #4
Credit Card
Loan
Misc. Debt.
Debt #5
Credit Card
Loan
Misc. Debt.
Debt #6
Credit Card
Loan
Misc. Debt.
Debt #7
Credit Card
Loan
Misc. Debt.
Debt #8
Credit Card
Loan
Misc. Debt.
Debt #9
Credit Card
Loan
Misc. Debt.
Debt #10
Credit Card
Loan
Misc. Debt.
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Monthly Spending Worksheet
Please list all information as truthfully & accurately as possible.
Section A – Sources of Income
*
Rows
Monthly Income
Income (from all household members)
Additional Income (second or side job)
Child Support
Food Stamps
Section B – Expenses
*
Rows
Monthly Expense
Rent/Mortgage
Renters/Homeowners Insurance
Utilities (electric, gas, etc.)
Internet
Cable/Subscriptions (Netflix, Hulu, etc.)
Groceries
Car Payment
Car Insurance
Gas
Health Insurance
Prescriptions
Daycare
Cell Phone
Debt (Totaled from Debt Worksheet on Previous Page)
Other
Income Total
Expenses Total
NET Income
Additional Info
Do you have any additional information you'd like to share?
Typed Signature
*
By typing my name above, I am authorizing the submission of this document & indicating that the preceding information is true to the best of my knowledge.
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Submit
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