Application Ignite Transform Application Begin Your Healing Journey by telling us about yourself!Welcome to IGNITE! We are glad you decided to take the first step on your healing journey. FIll out the application to the best of your ability and a member of the IGNITE team will reach out to set up the initial consultation to learn more about you as well as tell you more about the IGNITE program! Your Personal InformationYour Name(Required) First Last DOB(Required) Your Email Address(Required) Enter Email Confirm Email Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Your Phone(Required)Best Time To Call You(Required)When is the best time for us to reach you via telephone?MorningsEarly AfternoonLate AfternoonEarly EveningHousing & IncomeHousing & Income(Required) Own Rent How many people are in your household?(Required)How many people including yourself are living within your home?Are you currently a mom of a child less than 5 yo(Required)For IGNITE state grant qualification Yes No Are you a foster or adoptive family?(Required)For IGNITE state grant qualification Yes No Total Monthly Income for the Household(Required)Employment StatusTime since last employment(Required)Place of Current Employment(Required)Social & Emotional and Addiction HistoryHistory of Mental Health Issues(Required) Depression Anxiety Generalized Panic Disorder Post Traumatic Stress Disorder Social Anxiety Disorder Postpartum Depression Other None Have you received previous MH counseling?(Required)MH = Mental Health Yes No Was it beneficial?If yes, tell us why it was helpful If no, please explain whySubstance Use Disorder History(Required)Check all that apply Alcohol Mind Altering Drugs Prescription Medications Other None Select AllIf other, please provide additional informationAre you Currently Sober?(Required) Yes No If yes, how long have you been sober?Hx of Eating Disorders?(Required)Check all that apply Overweight Bulimia Anorexia Body Dysmorphia Other None If yes, which recovery program do you attend?Clarify your experience with your eating issue?History of abuse?(Required)Check all that apply Physical Emotional Sexual Domestic Childhood Other None Are you comfortable working with:(Required) Female Trainers Male Trainers Either Goals and Barriers to Achieving Your GoalsWhy do you feel you need IGNITE Transform?(Required)Specify goals for the Mental Health portion of IT?(Required)Specify goals for Physical Wellness portion of IT?(Required)Specify goals for Spiritual Wellness portion of IT?(Required)List barriers to reaching your optimal(Required)Mental Health and WellbeingList barriers to reaching your optimal(Required)Physical Health and Wellbeing List barriers to achieving optimal(Required)Spiritual Health and WellbeingHow many hours can you commit to the IT program?(Required) 2 - 4 hours/week 4 - 6 hours/week More than 6 hours/weeks Giving back is an important part of the IT program(Required)What areas of community involvement interest you and what talents could you lend to this service?What motivated you to apply for the IT program?(Required)Please provide additional information(Required)That is important for IGNITE Transform to know or is significant in your journey to healing.Thank you for filling out the IGNITE Transform ApplicationYou have taken a very important first step and we look forward to walking alongside you on this journey! The IGNITE Team
