Client Help FormIf you are in a dangerous or emergency situation, please immediately call 911 or contact our 24/7 Helpline! 937.426.2334Today's Date *Date of Birth *First Name *Last Name *Are you additionally seeking services for child(ren)? If so, please provide their name(s) and date of birth(s). *YesNoChild 1: Name & Date of BirthChild 2: Name & Date of BirthChild 3: Name & Date of BirthChild 4: Name & Date of BirthDo you have pet(s) that will need safety? *YesNoIf so, please list how many and their breed(s).Mobile Number *Is it safe to call? *YesNoIs it safe to text? *YesNoIs it safe to leave a voice message? *YesNoEmail Address *Is it safe to email? *YesNoCurrent AddressStreet *Apartment, suite, etc.City *State *Zip Code *Service Requested (choose multiple services, if needed) *Safe HousingCase ManagementCounselingYouth CounselingHealthy HomesGroups for YouthSexual Assault Survivor Support Group (SASS)OtherWhat are your current concerns? *0 / 150In your current relationship, what have you been impacted by? *Emotional AbuseMental AbuseVerbal AbuseFinancial AbusePhysical Assault: As a childPhysical Assault: As an adultSexual Violence: As a childSexual Violence: As an adultStalking/HarassmentStrangulationHuman Trafficking: LaborHuman Trafficking: SexIn your lifetime, what have you been impacted by? *Emotional AbuseMental AbuseVerbal AbuseFinancial AbusePhysical Assault: As a childPhysical Assault: As an adultSexual Violence: As a childSexual Violence: As an adultStalking/HarassmentStrangulationHuman Trafficking: LaborHuman Trafficking: SexSubmitGET HELP NOWIf you or someone you know might be experiencing domestic violence, Call or Text our Advocates.24-Hour Helpline937.426.2334
