Intake Form — The Swan Center for Advocacy & Research, Inc.

Seeking Support?

Please fill out the intake form below and allow 24-48 hours for follow-up. Please ensure the email and other contact options provided are safe to receive updates/feedback. If not please indicate that in the form below.

Name

First Name

Last Name

Address

Age

DOB

Race/Ethnicity

Phone

Preferred Pronouns (she/her, he/him, they/them, zir/zhe)

Gender Identity

Type of violence experienced

Location of Incident (if possible

Has this been previously reported? If yes, with what agency/institution has this been reported?

DId you sustain injuries? If yes, please describe the injuries.

Have you received medical attention? Are you planning to receive attention?

What type of advocacy are you requesting?

How were you made aware of the center?

Explain the incident/experiences in great detail.

Are you seeking a hardship fund? If yes, please list desired amount and expenses.

Preferred Method of Receiving Hardship Funds

Please list your name tag or handle for your preferred payment method.