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Contact Us

Mailing Address: PO Box 1532, Clarksburg MD 20871

We are happy you are here! Let us know how we can help.

I am...

an individualrepresenting an organization

What are you looking for?

I need help

I want to help

I’m interested in...

Clinical support from a licensed mental health professionalPeer Support GroupEducation and training

I'm interested in becoming a...

Wellness AmbassadorProvider - Licensed MHP (including interns, provisional, and graduate) and Alternative ProvidersTrained Peer SupporterPartner

Organization Information

Name of Organization

Address 1

Address 2

City

State

Zip Code

Website

Contact Information

First Name

Last Name

Mobile Phone Number

XXX-XXX-XXXX

Title

My address differs from that of my business.

Address 1

Address 2

City

State

Zip/Postal Code

How did you hear about Give an Hour?

If Other, please let us know how you heard about us below.

If Other, let us know your experience of concern that brought you here today:

We're interested in...

Collaborating and partnership Receiving education and training Enrolling as a group mental health practice Select all that apply

Birthdate

Gender

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Race/Ethnicity

Specify Race/Ethnicity

Insurance Status

Insurance Carrier

Select "Other" if none of the options above apply.

If Other, please specify:

Type of counseling requested

IndividualCouples

Service Member or Veteran

Role

Branch Affiliation

Rare Disease

Role

What Rare Disease are you or your family affected by?

Interpersonal Violence

Role

What type of interpersonal violence have you experienced:

Please Specify:

When did the event first occur?

Financial Fraud

Role

Reason for request (Briefly describe what type of financial fraud experienced. Please give as much detail as you are comfortable with.)

When did the crime or event first occur?

Mass Violence

Role

What mass violence event were you affected by?

Organization Type:

Who is the intended audience for the training?

Please Specify:

What community does your organization currently serve?

Please Specify:

Type of Partnership:

Are there any other details you'd like to share with us?

Partnership Timeline:

I have an event date in mind:

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Enter Event Date:

By submitting this form, you agree to all Give an Hour’s terms and conditions.

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By submitting this form, you agree to all Give an Hour’s terms and conditions.

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