NJ Hope & Healing Enrollment Form

First Name

First Initial of Last Name

Mobile Number*

Email Address

County of Residence*

Gender*

Age*

Race/Ethnicity*

(Please select all that apply.)

American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Hispanic or Latino

If you have a disability, or other access or functional need, please indicate the type.

(Optional - Please select all that apply.)

Physical (mobility, visual, hearing, medical, etc.)
Intellectual/Cognitive (learning disability, developmental delay, etc.
Mental Health/Substance Abuse (psychiatric, substance dependence, etc.)

Please note any concerns or issues you would like to disclose.

(Optional)

Are you interested in being directly linked to crisis counseling?*

Crisis counseling helps survivors understand their reactions, improves coping strategies, reviews their options, and connects with other individuals and agencies that may assist them. By clicking yes to Crisis Counseling, you are agreeing to have your contact information sent over to a trained crisis counselor. You will be contacted by a crisis counselor within 24 hours of enrollment. If this is a medical emergency and you need immediate assistance, please call 911

Yes
No

Terms & Conditions*

By clicking this box, I acknowledge that I have accepted the Terms & Conditions for this program.

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