Intake Form
If you’re coming from a church or religious environment that felt controlling, confusing, or unsafe, you’re not alone. This form is a way to tell us what you’re dealing with and what kind of support you want. All of the information you share will be kept strictly confidential. (If you report that you're planning to harm yourself or someone else, we are legally obligated to tell someone.)

Before we start:
  • You’re in control here. Share as much or as little as you want.
  • You can skip any question.
  • We won’t pressure you to use certain labels (like “deconstruction”) or arrive at a specific set of beliefs. Our goal is support, safety, and next steps—on your terms.
If you are in immediate danger or need urgent help, please call your local emergency number (in the U.S., call or text 988 for the Suicide & Crisis Lifeline, or call 911 if you’re in immediate physical danger). We are not an emergency service and can’t provide immediate crisis response.
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What name would you like us to use? (Feel free to use a nickname or a pseudonym.)
Where are you located? (Please don't share addresses, or any info you aren't comfortable with. Nation and region/province/state is plenty!)
Would you like to speak to someone from Deconstruction Doulas?
Clear selection
Do you have a preference for who you would like to speak with?
Your preferred method of contact (if any):
Contact info for your selection(s) above:
Is this contact method private and safe for us to use?
If you answered "no" above, use this space to share your concerns (if you're comfortable).
Is it safe for us to mention religion or church in our communication?
Anything else we should know in order to contact you safely (particular times of day, days of the week, etc.)?
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