Women Safety Screening Form
Please complete this form to help us understand your safety situation and support needs. All questions are focused on your current circumstances and how we can best assist you.
Full Name
*
First Name
Last Name
Preferred Contact Method
*
Phone
Email
Text Message
Do not contact me
Current Location (City/Town, State)
*
Are you currently in a safe place?
*
Yes
No
Not sure
How urgent is your current situation?
*
Immediate danger
Needs attention soon
Non-urgent, seeking information/support
Date and Time of Most Recent Incident (if applicable)
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Incident or Concern
*
Please Select
Physical safety concern
Emotional or psychological distress
Threats or intimidation
Harassment or stalking
Other (please specify)
Briefly describe your current situation or concern
*
Have you accessed any support or resources already?
*
Yes
No
Preferred Next Step or Support Needed
*
Speak to a support worker
Receive information/resources
Safety planning assistance
No follow-up needed
Other
Submit
Should be Empty: