Confidential Advocacy Intake Form

All information is kept strictly confidential. This helps us understand your situation so we can support you effectively. • Application Window Opens: January 1, 2027 • Final Submission Deadline: March 31, 2027

First Name

Last Name

Email

Phone

Situation Overview

Age of Individual

Location

Urgency Level

Immediate danger

Urgent (within days)

Ongoing concern

Seeking guidance

Additional Details

Please describe: - What is happening - Any actions already taken - If this has been reported before (and to whom)

I understand this is advocacy support and not emergency services