Domestic Violence Survivor Story Consent Form
Submit your story and provide consent for its use. Your privacy and safety are our top priorities.
Full Name (You may use initials or leave blank for anonymity)
First Name
Last Name
Email Address (for follow-up or clarification, optional)
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Your Story (Please share your experience. Do not include any information that could identify you or others if you wish to remain anonymous.)
*
May we share your story?
*
Yes, you may share my story with my name.
Yes, you may share my story anonymously.
No, please keep my story confidential.
Would you like to be contacted for follow-up, support, or advocacy opportunities?
*
Yes, you may contact me.
No, please do not contact me.
Submit Consent and Story
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