SheltHer Pilot Intake Form

1

Welcome to SheltHer.
SheltHer is currently in pilot development.
We are not offering emergency services or guaranteed coverage at this time.
All responses are confidential, voluntary, and reviewed manually.
If you are in immediate danger, please call 911.

2

Name* This field is required.

First Name

Last Name

3

What's the safest way to contact you?* This field is required.

Email

Phone

Text

I'll contact you

4

Email

example@example.com

5

Phone Number

Please enter a valid phone number.

6

What city and state do you live (or are currently staying) in?:* This field is required.

7

How did you hear about SheltHer?

8

Have you experienced harm or thread of harm in the past 12 months?

Yes

No

Prefer not to say

9

Do you feel safe in your current environment?

Yes

No

Sometimes

10

If support were available today, what type would you need most urgently?* This field is required.Check all that apply

Emergency relocation or housing

Emergency Transportation (including flights, train tickets, etc.)

Private security

Help filing police or hospital reports

Legal support

Mental health support

I'm not sure

Other (please use the "additional information" box at the end)

11

Please describe your current state of need:* This field is required.

I need support right now

I might need support in the future

I'm not sure

12

What is your monthly income?We use this to estimate cost and scale. No billing, no pressure

Less than $1,000

$1,000-$3,000

$3,000-$5,000

$5,000-$10,000

$10,000+

13

Would you opt into sliding-scale emergency coverage?

Yes

No

Maybe - I'd need more info

14

Is there anything else you'd like to share with us?

15

Please confirm the following:* This field is required.

I understand that SheltHer is in a pilot phase and does not currently provide insurance coverage, benefits, or guaranteed services. My participation is voluntary.