Online Orientation for Advocacy, Support Group and Referrals Step 1 of 4 25% About YouFull Name(Required) Contact Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required) MM slash DD slash YYYY Email Additional way to reach you Occupation What is the safest way to contact you? Are you currently living in a safe environment? Yes No Do you have a safe word? Yes No Do you have a safety plan? Yes No Do you need assistance creating a safety plan? Yes No Do you have a go bag? Yes No Do you need assistance creating a go bag? Yes No Part TwoReferring Agency, Service or Organization Their Address Their Phone Number Their Email Have you previously used our Organization? Yes No I don't know When did you use our Organization Has a partner used our Organization? Yes No I don't know When did a partner use our Organization Involved OrganizationsProbationIs Probation involved? Yes No Name of Officer Officer's Email Probation County Officer's Address Street Address City State / Province / Region End date of probation MM slash DD slash YYYY Social ServicesIs Social Services involved? Yes No Name of Social Worker Social Worker's Email Social Worker's County Social Worker's Address Street Address City State / Province / Region AttorneyIs an Attorney involved? Yes No Name of Attorney Attorney 's Email Attorney's Address Street Address City State / Province / Region Are there any court cases? Yes No Court Case #sEmergency Contact InformationEmergency Contact Name Emergency Contact Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Women's GroupWhat are three life goals that having an abusive partner has prevented you from accomplishing?What are three goals you want to accomplish to keep you safe? (For instance, Housing, Order for Protection, Job, School)Will you be attending Women's Group? Yes No What do you hope to learn in Women's Group?Please prove you're human.
