Safe Heart Claim Form

Safe Heart Claim Form

Welcome to Safe Heart — a gentle, supportive space for healing, reflection, and being heard.
Name or Alias
Email
example@example.com
Please verify that you are human*
About You
Date of Incident

MonthDayYear
Date
What brought you here today?

BreakupGhostingDivorceEmotional GaslightingSituationship FalloutUndefined Relationship EndingBetrayalUnreciprocated LoveOther
Tell Us What Happened
How long were you together?*
Who ended it?*

I didThey didIt was mutualHonestly still not sure
How long ago did this happen?*
Did you see it coming?*

Not at allI had a feelingI saw every sign and ignored them all
On a scale of 1–10, how heartbroken are you?*

1

2

3

4

5

1 is , 5 is Best
What emotion is showing up the most?*

SadnessAngerConfusionReliefAll of the aboveAsking for a friend
What's the hardest part of your day right now?*
Were you in love?

YesI thought soI'm not sure anymoreNo but I wanted to be
Was this your first serious relationship?*

YesNoDefine 'serious'
Were you in love?*

YesNoI thought soI'm still figuring that out
Did you see it coming?*

YesNoThe signs were there but I chose loveAbsolutely blindsided
What Did You Want From Them That You Never Received?
What Would Closure Look Like For You?
The Incident Report
Have you filed a claim before?

No, this is my first timeYes, I'm a returning claimantI practically have a loyalty card
What's the most valuable thing you lost in this breakup?*

TimeTrustConfidenceA really good playlistMy favorite hoodieAll of the above
What would help you feel seen and supported?

An ApologyTime BackA Handwritten LetterEmotional ReparationsTherapy MoneyA Trip To ItalyOther
Your Emotional State
What have you tried so far to feel better?*

Ice creamCrying to musicTherapyJournalingBlocked them on everythingTold everyone they were terribleNothing yetOtherOther
What do you actually need right now?*

To be heardAdviceA distractionValidationAll of the above
Would you like some extra support?

A Licensed TherapistA Certified Life CoachA Relationship AdvisorI'm not sure - just exploring
Would you be open to being part of something bigger?

Sharing this story on the Safe Heart PodcastBeiing interviewed for a future episodeContributing a written reflectionSubmitting a photo/art pieceNone of the above - just needed to vent
What have you tried so far to feel better?

CryingIce creamTherapyBlocked them on everythingJournalingTalking to friendsNothing yetOther
If your story is ever shared, how would you like to be known?

Use my first nameUse my last nameUse an aliasKeep it completely anonymous
Should be Empty:

Safe Heart Claim Form

About You

The Incident Report

Your Emotional State