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Hotline Inquiry
Questionnaire
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
Your answer
Contact number or email
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
*
Male
Female
Prefer not to say
Other:
Current City
Your answer
Number of children
*
Your answer
Age and gender of children
Your answer
Are you currently somewhere safe?
Yes
No
Maybe
Other:
Clear selection
Do you need a safety plan or more information?
Yes
No
Other
Clear selection
Do you have transportation?
Yes
No
Other:
Clear selection
Please check all that apply to your situation.
Domestic Violence
Homeless
Family Violence
Sex Trafficking
Human Trafficking
Mental Health
Drug Addiction
Alcohol Addiction
Other:
Please choose all that apply.
Alaskan Native
American Indian
Black or African American
Native Hawiian
White
Other:
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Unknown
Other:
Clear selection
Any additional details you'd like our crisis advocate to know?
Your answer
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