Request for Services (RFS)

Request for Services

We are glad you have reached out to us and would like to try our services. Please complete this form in as much detail as you are comfortable providing. If you are in crisis and need to speak to someone immediately, please call our free, confidential 24/7 helpline at 859-253-2511. A trained advocate will always answer and is ready to talk to you.
Name*

First NameLast Name
I am a*

SurvivorFamily/friend of a survivorSVRC Staff/InternCommunity member
Staff/Intern Name

First NameLast Name
I am seeking services for*

MyselfMy loved one
We are glad you're here and that you want to help the survivor you care about.

NOTE: We do not accept requests by third parties on behalf of someone else, unless it is a child or an adult with a legal guardian.

We would be glad to work with you to determine whether or how you can talk directly with your loved one about requesting our services, what we offer and how you could support them in reaching out to us.

If you have questions or would like further assistance, call us at 859-253-2511.
Date of Birth

MonthDayYear
What can we help you with? Is there anything about your experience that you would like us to know?*
How can we be helpful to you? Are there a few things in particular you can name that are priorities for you? What would you like to be different as a result of your time with us? i.e., I'm worried about how this will impact my school/work performance. I was abused as a kid but never got help. I was just sexually assaulted last week at work. I just told my partner about what happened and that was difficult.
Are you currently working with another person (crisis counselor, therapist, faith leader, trusted friend, etc.) about some of the things you need help with. This helps us understand what your support looks like and if there are others you might want us to connect with to better help you.
ie: My faith community is helping me find housing. I am currently staying at Greenhouse17. I am working with a therapist.
For how long have you been experiencing the challenges that prompted you to ask for help?*
ie: 3 months, 2 years, 10 years, etc.
Contact Information
Have you been an SVRC client before?*

YesNoI don't know
How did you hear about or find SVRC ?
Address

Street Address

Street Address Line 2

CityState

Zip Code
County*
Phone Number*

Area CodePhone Number
Email
example@example.com
We will attempt to contact you twice by the preferred method (phone, text, email) that you tell us.

Please be sure to check for voicemails or texts from us and contact us again if you have not heard from us within 5 business days.
Would you prefer that we block our number when we call you?*

Yes - block the numberNo - do not block the numberNo preferenceIt is not safe to call me. Please text first.
Please select all that are safe:

It is okay to say SVRC is callingIt is okay to leave a voicemailIt is okay to leave a message with another person.It is okay to text at this number
Preferred form of contact

Phone callTextEmail
If you selected that it is okay to leave a message with another person, what is the name of the person(s) we may leave a verbal message with?
ie: Jane Doe - mom
We will try our best to reach you at a time that works best for you. If we miss you and we have your permission, we will leave a voicemail with instructions on how to return the call.
During business hours, Monday-Friday, when is usually the best time to reach you? Also, please clearly indicate if there is a time that it is unsafe to reach you.
ie: 3p-5p on weekdays works well for me, 9a-1p is unsafe to call
Accessibility Needs
Do you have any accessibility concerns that we can help with, such as trouble getting up stairs or reading written documents?
In order to make sure that you are as comfortable as possible in our space, we like to check in to see if there are any accommodations we can make.
Please tell us about any transportation concerns you may have.
ie: I take the bus, I will need help getting to any appointments.
Is there a language other than English you would prefer to receive services in?
ie: Spanish, ASL, Swahili
Is there anything else you'd like us to know?
Form completed by:

First NameLast Name

Request for Services

Contact Information

Accessibility Needs

What happens next?