You’re Not Alone – We’re Here to Help

Your safety and confidentiality are our highest priorities. Please fill out this form as much or as little as you feel comfortable. You’re not alone, and help is available.

Basic Information

Gender

Location

Is this report about yourself or someone else?

What type of support do you need? (Select all that apply)

Basic Information

What is the nature of the issue you are reporting?

Timing and Frequency

When did this incident occur?

Is this a recurring issue?

Safety and Urgency

Do you feel you are in immediate danger?

How urgently do you need assistance?

Do you need help with finding a safe place to stay?

Preferred Method of Contact

How would you prefer to communicate with us?

If you’re comfortable sharing, please provide your preferred contact information: (Provide space for a phone number, email, or other relevant details)

Consent and Confidentiality

Do you consent to share the information you provide with support professionals who can assist you?

Would you like us to follow up with you about the status of your case?

Final Optional Comments

Is there anything else you’d like us to know?