I Am A Safe Place - Survivor Support Fund Application Please fill out this form to help us understand your needs and how we can assist you through our support fund. Your information will remain confidential. Survivor Support Fund Application Contact Personal InformationFirst NameLast NamePhone/MobileEmailAddress Line 1CityStateZip CodeDemographicsSome description about this sectionAgeGender Identity Female Male Non-Binary Prefer not to say OtherPlease SpecifyRace/Ethnicity Black or African American White Hispanic or Latino Asian Native American Pacific Islander OtherMarital Status Single Married Hispanic or Latino Divorced Widowed In a Relationship SeparatedAre you a veteran? Yes NoCurrent SituationAre you currently experiencing domestic violence? Yes NoIf yes, please briefly describe your situationPerpetrators NameSupport NeededPlease check all areas where you require assistanceLegal Support Legal Consultation Court RepresentationCounseling Services Individual Therapy Group TherapyTransitional Housing Rent Assistance Utilities Assistance Emergency ShelterChildcare Support Assistance with Childcare Costs Educational Resources for ChildrenFood Assistance Grocery Vouchers Meal SupportTransportation Assistance Bus Passes Group TherapyOther (please specify)Financial InformationWhat is your current source of income?Do you have any financial support from family or friends? Yes NoIf yes, please specifyWhat is your estimated monthly budget for living expenses?Children’s Information (if applicable)Number of ChildrenAges of ChildrenHealth InformationDo you have any physical or mental health conditions we should be aware of? Yes NoIf yes, please specifyDoes your children have any physical or mental health conditions we should be aware of? Yes NoIf yes, please specifyGoals and PlansWhat are your immediate goals for the next 3 months?How do you believe our support can help you achieve these goals?Emergency Contact InformationNameRelationshipPhone/MobilePreferred Method of ContactHow would you like us to contact you? Phone Email In-PersonCultural or Language ConsiderationsDo you have any cultural or language needs we should be aware of to provide appropriate support? Yes NoIf yes, please specifyAdditional Comments or ConcernsIs there anything else you would like to share that may help us assist you better?ConsentI consent to share this information with I Am A Safe Place for the purpose of receiving support. YesSubmit Form
