Safe Heart Claim Form
Name or Alias
Email
example@example.com
Date of Incident
-
Month
-
Day
Year
Date
Type of Claim
Breakup
Ghosting
Divorce
Emotional Gaslighting
Situationship Fallout
Undefined Relationship Ending
Betrayal
Unreciprocated Love
Other
Tell Us What Happened
What Did You Want From Them That You Never Received?
What Would Closure Look Like For You?
What Kind Of Reimbursement Do You Feel You Deserve
An Apology
Time Back
A Handwritten Letter
Emotional Reparations
Therapy Money
A Trip To Italy
Other
How Should We Refer To You If We Share Your Story
Use my first name
Use my last name
Use an alias
Keep it completely anonymous
Would You Be Open To...
Sharing this story on the Safe Heart Podcast
Beiing interviewed for a future episode
Contributing a written reflection
Submitting a photo/art piece
None of the above - just needed to vent
Would you like to be connected with....
A Licensed Therapist
A Certified Life Coach
A Relationship Advisor
I'm not sure - just exploring
Please verify that you are human
*
Submit
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