Request for Services (RFS)

Request for Services

Please complete this form in as much detail as you are comfortable. We are currently under-staffed, and experiencing longer than usual response times. If you are in crisis and need to speak to someone immediately please call our support line at 859-253-2511. A trained advocate will always answer that line and is ready to talk to you.
Name*

First NameLast Name
I am a*

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

First NameLast Name
I am seeking services for*

MyselfMy loved oneA client of mine (I'm a counselor, advocate, physician, etc.)
We do not accept submissions on behalf of someone other than the individual completing the request. We are glad that you are here and that you want to help the survivor you care about. We can work with you to determine whether/how to discuss directly with the survivor the services we offer and how you could support them in reaching out to us. Please fill out the form with your name and contact info if you would like us to reach out to you regarding how to get your client involved in services. If you are filling this form out with the survivor, please click the "myself" option listen above.
Ampersand provides support to survivors of sexual violence and anyone who supports them. If you have a loved one who has experienced sexual violence, we are happy to provide you with support. We do not accept submissions on behalf of someone other than the individual completing the request. We are glad that you are here and that you want to help the survivor you care about. We can work with you to determine whether/how to discuss directly with the survivor the services we offer and how you could support them in reaching out to us. If you have questions, please call or email us.
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? ie: 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 anyone else to address 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, 6 years, etc
Contact Information
Have you been an Ampersand client before?*

YesNoI don't know
How did you hear about or find Ampersand?
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 phone. Please be sure to check for voicemails or texts from us and contact us again if you have not heard from us within a week.
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 Ampersand 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
What is the name of the person/people with whom we can leave a verbal message?
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.
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

Next Steps