PEACE Collaborative Services

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Ready to rebuild your life and accomplish your goals? Fill out the info below and we will contact you within 2-3 business days to schedule your first 1-to-1 meeting. This service is completely free and available to any Jackson County survivor of domestic violence, sexual assault, or human trafficking.

What is the name of your Advocate at CDP?

What is your first and last name? *

What is your preferred method of contact? Check as many as you'd like.

Phone- Calling

Phone- Texting

Please provide your phone number *

Please provide your email *

What types of goals are would you like to work on with the PEACE Collaborative? Check as many as you'd like.

Feeling Financially Secure- budgeting, credit issues, finding free/low cost services

Improve Physical Health- getting check ups, finding treatment, applying for health insurance

Feeling Mentally/Emotionally Well

Building Self-Esteem & Confidence

Advancing Education & Employment Opportunities

Maintaining Stable Housing

Dealing with Legal Issues- custody, divorce, probation etc.

Navigating "The System", i.e. birth certificates, social security cards, car registration, etc.

Other:

Are you interested in attending a survivor support group?

Yes

Maybe

Clear selection

Would you like to be notified about upcoming workshops and free events?

Yes

Clear selection

Anything else you'd like us to know?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Center for Domestic Peace.

Does this form look suspicious? Report

Forms