Safe Space Carolinas Intake, Consent, Release, and Services Agreement

Safe Space Carolinas Intake, Consent, Release, and Services Agreement

Please complete this form to help us understand your needs and obtain your consent for services. This form supports both individuals and families, while preserving family/child-specific steps where needed.
Client Intake (Individual or Family)
Are you seeking services as:
If you are an individual, please describe your primary support needs
Individual/Parent/Guardian Full Name #1

First NameMiddle NameLast Name
Perferred Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Individual/Child(ren)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Secruity Number
(XXX-XX-XXXX)
Email Address
example@example.com
Individual/Parent/Guardian Full Name #2

First NameMiddle NameLast Name
Perferred Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Secruity Number
(XXX-XX-XXXX)
Relationship to Individual/Child(ren)
Single Parent
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Is your household
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Communication Method
Household Language Support Needed

Other
Individual(s) #1
Individual(s) #2
Child Participant(s) #1
Child Participant(s) #2
Child Participant(s) #3
Child Participant(s) #4
Child Participant(s) #5
Child Participant(s) #6
Authority to Consent for Minor(s)
Custody / Authority Details (if applicable)
Requested Services / Please select any services you need

Other
Important Note: Services and assistance are based on availability, eligibility, funding, donations, and community partner support. Self-registration does not guarantee approval, but it allows Safe Space Carolinas to review needs and connect individuals or families with the best available support.
Consent, Program Terms, and South Carolina Legal Notices
I agree to the intake consent and participation terms
Consent for program participation
Authorize emergency contact when needed
I understand the limits of services provided
I understand the trauma-informed services expectations
I agree to follow conduct expectations
I acknowledge the nonprofit services release and acknowledgment
Notice: This form is not legal advice and should be reviewed by South Carolina counsel. If you select Disagree to the required service terms, Safe Space Carolinas may be unable to provide services until staff review.
Privacy, Confidentiality, and Information Sharing
Partner Sharing Consent
Permitted Information Sharing

Other
Privacy and Confidentiality Acknowledgments
Consent to Share Information with Partners
Communication Consent for Service Coordination
Authorization for Security and Privacy Notices
Additional Privacy or Sharing Instructions
Minor Assent / Child Participation
Child Assent Statement
Child's Name #1

First NameLast Name
Child's Age
Date of Birth

MonthDayYear
Date
Social Security Number
(XXX-XX-XXXX)
Child's Name #2

First NameLast Name
Child's Age
Date of Birth

MonthDayYear
Date
Social Security Number
(XXX-XX-XXXX)
Child's Name #3

First NameLast Name
Child's Age
Date of Birth

MonthDayYear
Date
Social Security Number
(XXX-XX-XXXX)
Child's Name #4

First NameLast Name
Child's Age
Date of Birth

MonthDayYear
Date
Social Security Number
(XXX-XX-XXXX)
Child's Name #5

First NameLast Name
Child's Age
Date of Birth

MonthDayYear
Date
Social Security Number
(XXX-XX-XXXX)
I understand and agree to participate in a safe, age-appropriate way, and I can ask questions any time.
Upload Photos & Documents
Upload photos and documents

PDF, JPG, or PNG files. You can upload multiple files.
Cancelof
Document type(s) — select all that apply
If Other, please specify
Release / Signature / Submission
Printed Name

First NameMiddle NameLast Name
Signature Date

MonthDayYear
Date
Authority and Final Acknowledgment
Electronic Signature
Should be Empty:

Safe Space Carolinas Intake, Consent, Release, and Services Agreement

Client Intake (Individual or Family)

Consent, Program Terms, and South Carolina Legal Notices

Privacy, Confidentiality, and Information Sharing

Minor Assent / Child Participation

Upload Photos & Documents

Release / Signature / Submission