Survivor Intake Form We’re here to support you in a safe, confidential, and nonjudgmental space. You control what you share and how we follow up. If you’re in immediate crisis, you can request urgent support at any time. Preferred Name: Gender: Male Female Age: Select 18–24 25–34 35–44 45–54 55+ Location (City/State): Best Way to Contact You: Phone Email Text Other Contact Details: About Your Experience (Optional) Have you experienced: Abuse Neglect Both Prefer not to say How long did the abuse or neglect occur? Who was responsible? Support Needs (Check all that apply): Mentoring Therapy Referral Life Skills Classes Scholarships Advocacy/Legal Support Housing/Financial Assistance Other What are you hoping to get support with right now? (Optional) Is there anything you want us to know about how to safely contact or follow up with you? (Optional) Are you currently in crisis or immediate distress? Yes (we will provide crisis intervention contacts and support) No Privacy & Confidentiality: Your information is confidential and protected. We only use your details to support you and will never share them without your consent, unless required by law for your safety. You control what you share and how we follow up. A trauma-informed team member will reach out using your preferred contact method. You can pause or stop contact at any time. If you’d like to remain anonymous, you may skip any question. Thank you for reaching out. You are not alone. For questions, contact us at admin@risingfromshadows.com or (330) 468-2468. Submit
