Application for psychological support

Виберіть мову у верхньому правому куті форми
Інформація, яку ви надасте в цій формі, є повністю конфіденційною, її побачить лише ваш координатор і передасть лише вашому терапевту.
Please confirm your email*
Your full name*

First NameLast Name
Phone Number*

Country CodePhone Number
To get you the help you need as quickly as possible, one of our team members—whether a coordinator, translator, or therapist—will reach out to you directly via messenger
Number for messengers*

Country CodePhone Number
WhatsAppTelegramViberOther
Current city and country of residence *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
YesNo
Please give your child's age
Health Information
How would you rate your mental health condition? *

1

2

3

4

5

6

7

8

9

10

1 is Very Poor, 10 is OK
Please provide a description of the issue*
Please describe how you are affected by the war
Other information you feel is important (optional)
Language and therapy preferences
NoneBasicGoodFluent
UkrainianEnglishPolishGerman
Female therapistMale therapistEither
Ukrainian-speaking psychologistEnglish-speaking therapist (from US or Western Europe) with a professional Ukrainian interpreterNo preference. I am comfortable with either option. Please match me with the first available specialist.
Since your English proficiency is good or fluent, you have the option to work with an international specialist. Please select your preference below.

Note: Choosing "No preference" option is highly recommended. This allows us to tap into our wider pool of both international and Ukrainian specialists to find one best-suited to your specific needs.
English-speaking therapist (from US or Western Europe)Ukrainian-speaking psychologistNo preference. Please match me with the first available specialist (recommended)

Your available days and times for therapy. Please check all that apply

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Any time of day
9:00 - 15:00
15.00 - 21.00

Recommendation from a family memberRecommendation from a friendSocial workerReferral from a medical or mental health professionalBrainspotting Help websiteInstagramFacebookOther
After clicking "Submit" button, please check your inbox for an email containing a link to our consent form, which outlines our support procedures and policies. Read and sign it online and our coordinator will begin to organize your support sessions.
Should be Empty:

Health Information

Language and therapy preferences