Contact/Screening Form

Contact/Screening Form

The Women’s Center of New Bedford provides free and confidential services for survivors of domestic violence and sexual assault in the South Coast region of Massachusetts. If you are outside this area, we can connect you to resources in your community.Your information is confidential and will only be used by our trained staff to respond to your request. Please allow up to two business days for staff to respond to your inquiry and If you are in immediate danger, please call 911 or our 24-hour hotline at 508-999-6636

By continuing with this FORM you understand the above statement
Are you reaching out for yourself?*
I am reaching out for myself today

Homelessness due to Domestic violence and/or sexual assaultFleeing Domestic ViolenceFleeing Sexual AssaultSeeking Counseling Advocacy ServicesLegal Advocacy and/or safe plan
Please briefly describe your current situation and specific needs.
Full Name

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Thank you for completing this form. A member of The Womens Center in New Bedford will get back to you within two business days. please take a look through our website for more information on services and if you would like immediate assistance please call our Hotline, on 508-999-6636
You are reaching out on behalf of a survivor
Thank you for reaching out to the Women’s Center of New Bedford. We appreciate your care and support for the survivor in your life. Our services are available directly to survivors of domestic violence and sexual assault in the South Coast region of Massachusetts. While we cannot provide confidential services on someone’s behalf, we can:

Share information, resources, and safety planning tips with you.
Guide you on how to support the survivor in safe and respectful ways.
Provide our 24/7 hotline number so the survivor can contact us directly when they are ready.
If the survivor gives permission, connect them with counseling, advocacy, or shelter services.

Please let us know if you’d like resources for yourself as a supporter, or if you’d like us to provide referral information that you can share with the survivor. If the person you’re supporting is in immediate danger, please call 911 or our hotline at 508-999-6636
Please leave your contact information and staff will respond to your inquiry*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Please indicate which resources and services you would like more information on to better support your survivor *
I am reaching out for another matter today

I am interested in volunteeringI would like to donate to TWCMy organization would like to collaborate with TWC
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Please indicate which services you are interested in volunteering your time for or how your organization would like to collaborate with us!
Should be Empty:

Contact/Screening Form

You are reaching out on behalf of a survivor