Healing & Clergy Triage Provider Network: Charlottesville Community Care Intake Form
This resource is for those involved and impacted by the action in Charlottesville, VA. If you need support from a care provider who can offer you remote phone, email and/or video chat support please fill out this form and we will do our best to connect you with a care provider who meets your needs as soon as possible from the Healers & Clergy Triage Provider Network.

Folks supporting organizing this include a number of individual healers and clergy, Auburn Seminary, Faith Matters Network, Mystic Soul Project, Center for Inclusivity and Standing on the Side of Love in collaboration with Congregate CVille. We will not share your information with other outside outlets and will be using your details specifically for the purpose & mission of this Healers & Clergy Triage Provider Network and connecting you with remote/virtual support and care.

Name *
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Pronouns *
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Contact Information (phone number, email address) *
Your answer
City/State
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Age *
Your answer
Who referred you to the Network?
Your answer
Do you have a preferred provider?
Your answer
Distress Signs *
Required
Need for support by ... *
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Provider Needs (check all that apply): *
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Any Other Information We Should Have...
Your answer
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