Name *

First Name

Last Name

Age

Under 18

18-24

25-34

35-44

45-54

55+

What type of assistance are you seeking? *

Mental health support

Legal assistance

Emergency housing or shelter

Financial assistance

Medical care

Peer support group or community connections

Advocacy and policy information

Other

Are you in immediate danger or need urgent assistance? *

Yes

No

Not sure

Have you experienced any of the following? *

Sexual assault or abuse

Domestic violence or intimate partner violence

Emotional or psychological abuse

Human Trafficking

Child abuse

Prefer not to answer

Have you previously sought help for this situation? *

Yes, through a therapist/counselor

Yes, through legal services

Yes, through family/friends

No, this is my first time seeking help

How are you feeling emotionally at this time?

Overwhelmed

Anxious

Depressed

Hopeful

Angry

Numb

Other

Do you currently have access to any mental health services (counseling, therapy)? *

Yes

No

I'd rather not say

Are you experiencing thoughts of self-harm or suicide? *

Yes

No

I'd rather not say

Do you feel safe where you currently live? *

Yes

No

Not sure

What type of support would you prefer from SAMA? *

A referral to professional services (therapy, legal, medical)

Peer support groups or community connections

Advocacy and information about changing policies

Educational workshops and resources

Help with emergency needs (housing, food, transportation)

Would you like to remain anonymous in your interactions with SAMA? *

Yes

No

Do you consent to sharing your information with service providers if referrals are needed? (Your personal details will remain confidential unless you give us permission to share them.) *

Yes

No

I need more information before deciding.