Safe Space Carolinas — Family & Individual Help Outreach / Assistance Interest Tracker
Use this form to record outreach efforts and support requests from families and individuals seeking assistance. Ensure all information is accurate for effective follow-up.
Internal Tracking and Contact Intake
Internal Use Notice
Client / Family / Individual Name
*
First Name
Middle Name
Last Name
Preferred Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Please Select
Phone
Text Message
Email
In Person
Other
Date and Time of Outreach
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Staff Member Name
*
Source / Referral
Please Select
Self-Referral
School
Healthcare Provider
Community Partner
Family/Friend
Social Media
Hotline
Other
Reason for Contact
*
Services / Referrals / Resources / Intake / Support Needs
Immediate Support
Resource Information
Referral Assistance
Intake Screening
Transportation Help
Housing Support
Food Support
Benefits Navigation
Legal Support
Mental Health Support
Other
Contact Status
*
Please Select
Reached
No Answer
Left Message
Wrong Number
Opt-Out
Other
Outcome / Next Step
No Answer
Declined Help
Requested Time to Think
Agreed to Proceed
Opt-Out
Follow-Up Scheduled
Information Sent
Other
Call Summary and Next-Step Guidance
Consent, Confidentiality, and Legal Notices
Acknowledgment of confidentiality limits
*
I understand confidentiality is limited by safety, abuse, and legal reporting obligations
Acknowledgment of mandatory reporting requirements
*
I understand certain concerns may require reporting to appropriate authorities
Emergency and crisis disclaimer acknowledgment
*
I understand this form is not for emergencies and immediate danger should be directed to emergency services
Are you currently in immediate danger or at risk of harm? If yes, please call emergency services (911) now. If not, do you feel unsafe or are you experiencing any form of abuse (for example: physical, emotional, sexual, financial, or other)? You may choose "Prefer not to answer".
Yes
No
Prefer not to answer
If yes, please describe any safety concerns, the type of abuse, or immediate needs (optional)
Do you consent to be contacted about this request?
*
Yes
No
Preferred contact methods
Phone
Email
Text message
Mail
Other
Do you consent to receive electronic notifications?
Yes
No
Do you allow us to send application or intake links?
Yes
No
Do you authorize us to assist with completing forms on your behalf when permitted?
Yes
No
Do you authorize us to request supporting documents related to your request?
Yes
No
Do you allow us to send a secure upload link for documents?
Yes
No
Compassionate Talking Points and Next-Step Guidance
Staff talking points covered
*
Hope
Support
Safety
Empowerment
Healing
Belonging
Dignity
Confidentiality
Next-step guidance
What was discussed
*
What the person shared, concerns raised, and any safety considerations
Agreed next steps and follow-up guidance
*
Follow-Up Templates and Staff Certification
Follow-up outcome
*
Please Select
Agreed to proceed
Declined help
Requested time to think
Missing documents
No answer
Opt-out confirmation
Copy-ready follow-up message
*
Message channel
*
Please Select
Text message
Email
Phone call note
Other
Permission recorded for this contact method
*
Text message
Email
Phone call
Voicemail
Other
Staff certification signature
*
Certification date and time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Accuracy attestation
*
Record confirmation
*
Information reviewed for accuracy
Consent and permissions documented
Follow-up template matches the selected outcome
Other
Are you an individual or representing a family?
Individual
Family
Single Parent Household
Do you have children?
Yes
No
If yes, how many children do you have?
Please list the age of each child (e.g., 8, 10, 15)
Are the child(ren) attending a school?
Yes
No
Homeschoold
If yes, what grade(s) are the child(ren) in?
If not attending school, are the child(ren) homeschooled?
Yes
No
Are you currently receiving any form of government assistance?
Yes
No
Prefer not to answer
If yes, please specify the type(s) of government assistance you are receiving (for example: SNAP, TANF, Medicaid, disability benefits, unemployment, housing assistance, other). If you prefer not to specify, you may decline to answer.
Save Tracking Record
Save Tracking Record
Should be Empty: