HNL ApplicationFirst Name Last Name Age Date of Birth Email Contact No AddressAddress Line 1 Address Line 2 City State Zip Code Relationship Status - Select -MarriedSeparatedDivorcedIn a RelationshipSingleIf currently in a romantic relationship, please describe the nature and overall health of the relationship. Do you have Children in the home? YesNoIf yes, how many? Please list children's names and ages here (if no children in the home, enter "N/A"). Are you currently employed? YesNoIf yes, what is your employers name? Are you currently residing or receiving services from a battered women's shelter, homeless shelter, rehabilitation facility, or re-entry or similar program? YesNoIf yes, please give specifics here (if no, please enter "N/A"). Do you have a criminal record? YesNoIf yes, please provide details, including dates, convictions, and any sentences served (if no, please enter "N/A"). Do you have any diagnosed mental and/or behavioral health conditions? If so, please list them here. Are you currently under the care of a Psychiatrist or Psychologist? If yes, please list their name and contact information here. Are you currently taking any Psychiatric medications? If so, please list them all. Sessions are on Tuesday and Thursday for 9 months. If selected, would you attend Day or Evening Sessions? Day Sessions: 10am - Noon Evening Sessions: 6-8pmIf selected, would you require childcare during session times? If so, for how many children and what ages? How did you hear about our Her New L.E.A.F. program? GBTM Website Referral Media (Facebook, LinkedIn, etc.) OtherBrief Statement of Interest - Tell us why you are interested in participating in this program? In what areas of your life, do you most desire change? Be as specific as possible here. Envision yourself 9-months from now. Who are you? What have you accomplished? What are your plans for your brand new future? How would you, your loved ones, and your community benefit from your participation in Her New L.E.A.F.? Please list 3 references (1 personal, 2 professional) by first & last name, relationship, email, and phone number. Submit Application