The Vine Visits - Request for Outreach Support
Faith-based, trauma-informed outreach for targeted women. Your answers help us ensure a safe, private, and compassionate visit. All information shared here is confidential and used only to coordinate your visit. Please answer honestly and to the best of your comfort.
Full Name (or Alias)
*
City or State
*
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Contact Method
*
Call
Email
Mail
Are you a
*
Targeted Individual
DV survivor
Survivor of Covert Abuse
All
How did you hear about The Vine Sisters?
Immediate Needs & Safety
What do you need most right now?
*
Toiletries
Feminine care
Snacks & water
Prayer & encouragement
Resource packet
Conversation or Visit
Other (write-in)
Other
Do you have any allergies or sensitivities?
*
Please share anything we should know to keep you safe during the visit.
*
Preferred meeting type
*
Home visit
Neutral location
Mail delivery only
Best days & times for contact or visit
*
Morning
Afternoon
Evening
Weekdays
Weekends
Follow-Up and Consent
May we follow up with resources after the visit?
Yes
No
Would you like to receive The Vine Sisters email updates (optional)?
Yes
No
If we can’t reach you, may we contact a trusted person to confirm you’re safe?
Yes
No
Trusted Contact Name
Trusted Contact Phone or Email
Would you consider sharing your story anonymously for awareness later?
Yes
No
OPTIONAL PRAYER REQUEST
Prayer & Encouragement
Would you like us to pray with or for you?
ACKNOWLEDGMENTS & AGREEMENTS
Agreements & Consent
I understand The Vine Sisters is a faith-based outreach offering non-clinical support.
I understand services and resources are limited and not guaranteed.
I consent to The Vine Sisters contacting me to coordinate a confidential outreach visit.
SUBMIT & CONFIRMATION
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