Request for Services
Kingdom Builders Family Life Center
Waitlist Process
We are a program that focuses on Black, Indigenous, People of Color, men, young adults, and children from marginalized communities, and at times have space for folks not meeting these criteria. Please fill out the following form and you will receive a call back to further assess available services. We will always refer if we cannot provide services.
Name
*
First Name
Last Name
Age
*
Gender
Woman (Girl if child)
Man (Boy if child)
Transgender
Non-binary
Other
Zip Code
*
Primary Race/Ethnicity
*
Asian
Black/African American
Hispanic/Latine
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White
Middle Eastern
African
Choose not to answer
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred method of contact:
*
Phone
Email
Preferred Time for Contact:
*
Morning
Afternoon
Evening
Days of the week you are available:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Have you received services from us before?
*
Yes
No
When did you last receive services?
*
Are you in a safe place?
*
Yes
No
What services are you looking for?
Have you experienced domestic violence by a romantic partner (like a spouse, boyfriend/girlfriend, former or current) or sexual violence?
*
Yes
No
Have you experienced non-intimate sexual violence and would like to access additional services?
*
Yes
No
What type of victimization?
*
Domestic violence
Sexual Violence
How long has it been since the last incident occurred?
*
A week ago or less
More than a week ago but less than a month ago
More than a month ago but less than 6 months ago
More than 6 months ago but less than a year
More than a year ago
Do you have any children?
*
Yes
No
What are their ages?
Will you be bringing your kids to your appointments?
*
Yes
No
Are you interested in enrolling your youth (ages 7-17) in our Youth Leadership Program?
*
Yes
No
Will you be bringing a service animal to your appointment?
*
Yes
No
How did you hear about KBFLC?
*
Consent and Agreement: I understand that I am adding my name to the service call back list by submitting this form. I agree to be contacted by Kingdom Builders Family Life Center when services become available. I confirm that the information provided is accurate to the best of my knowledge.
Submit
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