Intake Form

How can we help?

We value your privacy and safety. Anything you share with us will be kept confidential and will not be shared without your consent.

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Thank you for reaching out. We have received your request and a team member will contact you directly. Take care and stay safe.

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Where do you live?

Please select or write-in the topic that best represents why you’re reaching out.

Please fill out this section if you’d like to report an incident. Otherwise, skip to the next question. Please select all the checkboxes that apply to your incident.

Please share any further details about the incident if you have not already provided it above, such as:

  • who was involved in the incident?
  • when and where did the incident occur (date, time, location)?
  • is there proof of the incident or any witnesses?
  • how old were you when the incident occurred?
How would you describe your gender identity? Please select the option that best fits you or add your own description.

How would you describe your sexual orientation? Please select the option that best fits you or add your own description.

How would you describe your ethnicity? Please select the option that best fits you or add your own description.