CGLCC 2SLGBTQIA+ Entrepreneur Mental Health Initiative

Renewal & Additional Hours Application Form

Please complete this form to apply for additional funded hours in the program.

While we cannot guarantee any additional hours, we are working hard to ensure we are able to accommodate as many folks as possible.

We currently have a waitlist for renewals and will be offering these in order of when we receive your application. We will contact you as soon as you have been approved for additional hours.

If you have any questions, please contact Nicole at admin@ourlandingplace.com

Name

Please provide the name you would like us to use for you. This can be different than your legal name.

First Name

Last Name

Pronouns (optional)

Email

Phone

(###)

###

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I would like to continue working with the same therapist.

If you select 'no', Nicole will reach out to you directly when we have hours available to offer you to help connect you with a different therapist.

Yes

No

Please make sure to add admin@ourlandingplace.com to your email's safe senders list and check your junk/spam folder to ensure you don't miss an email from us. We will connect with you from this email address to offer you a spot in the program.