Registration: Elevate Program's Individual Mental Health Counseling
Our Elevate Program's individual mental health counseling offers a trauma-informed safe space to process the challenges that LGBTQIA+ youth and young adults (12-26yo) face on a daily basis. Services are free and will include 1-10 therapy sessions to assist youth and young adults in managing day to day mental health issues, building insight, healthy coping skills, setting healthy boundaries, decreasing substance use or maladaptive coping skills, understanding how to manage and decrease negative thinking patterns, and improving overall social relationships. 

After completing this form, interested youth and young adults are contacted by a therapist to complete intake paperwork and schedule the first session. 

This form can be accessed through this link:  bit.ly/elevate-counseling

Questions? Please contact:
Elevate Mental Health Counselors
Brittany Hardin, AMFT #144543
brittany.hardin@lgbtqcenteroc.org
Jordyn Dugan, AMFT #152309
jordyn.dugan@lgbtqcenteroc.org

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First Name *
Last Name *
Age *
Email *
Please list personal email and not school-affiliated email address.
Cell Phone
Do you live in Orange County, California? *
City *
Birthday *
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Pronouns *
Required
Gender Identity *
Required
Attraction Orientation *
Required
Race/Ethnicity *
Select all that apply.
Required
If you selected Asian, please share:
If you selected Native Hawaiian or Pacific Islander, please share:
Are you part of an Indigenous tribe? *
If you are part of an Indigenous tribe, please list the name.
Do you have secure housing? *
Housing insecurity is defined by experiencing any of the following: Having high housing costs in proportion to income; poor housing quality; unstable neighborhoods; overcrowding; or homelessness.
Are you currently in foster care? *
This includes group homes; residential care facilities; emergency shelters; and supervised independent living.
Have you entered into any of the following? *
Your answer does not impact your participation in the Elevate Program.
Required
How did you hear about this program? *
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