Section 1 — Personal Information
Full Name:
First Name
Last Name
City / State / Zip:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method:
Email
Text
Phone
Section 2 — Incident Information
Have you ever been stopped, detained, or questioned by law enforcement?
Yes
No
If yes, where did this occur? (City, State, or Department name if known):
Approximate date of the incident:
-
Month
-
Day
Year
Date
Were you given a clear reason for the stop?
Yes
No
Were you searched or handcuffed during the stop?
Yes
No
Did you feel you were treated differently because of your race, gender, or background?
Yes
No
Not Sure
If yes, please describe how you were treated differently:
Were there any witnesses present or body-cam footage that could support your account?
Yes
No
Not Sure
Did you file a complaint or report with the police department or city officials?
Yes
No
If yes, what was the outcome?
Were you charged with a crime or given a citation?
Yes
No
If yes, please specify:
How did this incident impact you emotionally, financially, or socially?
Section 3 — Legal & Support Needs
Do you currently have legal representation or a civil rights advocate?
Yes
No
Are you seeking assistance in filing a complaint or lawsuit?
Yes
No
Would you like to be connected with:
A civil rights attorney
A mental health or trauma counselor
A community liaison for police relations
A clergy or faith-based advocate
Have you experienced repeated or ongoing profiling or harassment?
Yes
No
Not Sure
Section 4 — Training & Prevention
Would you like to participate in Pivot America training sessions on how to safely engage law enforcement?
Yes
No
Interested in law enforcement therapy and training?
Yes
No
Interested in mental health therapy in law enforcement? (Law Enforcement ONLY)
No
No
Interested in setting up a PIVOT AMERICA chapter within your community?
Yes
No
What topics would be most helpful to you? (Select all that apply)
Understanding your rights during police encounters
How to de-escalate tense situations
What to do if stopped illegally
How to file a complaint effectively
How law enforcement can better serve communities of color
Would you be willing to share your story publicly to raise awareness (with your permission)?
Yes
No 2
Are you interested in volunteering or joining Pivot America’s outreach programs?
Yes
No
Section 5 — Final Reflection
In one sentence, what change would you like to see in policing in your community?
Is there anything else you want Pivot America to know about your experience or how we can support you?
Submit
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