Client Intake Form

Client Intake Form
Name*

First NameLast Name
Pronouns of Choice
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Non-Work Email*
example@example.com
Care Package (U.S. Only)Security Package (U.S. Only)Safety Planning Questions for Police ContactsBookclub participationReporting with funding agencies about sexual misconduct/ongoing investigationSocial Media MonitoringSocial Media AmplificationBest Practices 'Letter of Concern'Free and Anonymous FOIA filingDepartment of Justice FilingDialectical Behavior Therapy WaitlistMTSTalk ExpertiseLegal ReferralsNot Sure? Ask for an Intake ConsultationOther
YesNo
Human Resources ComplaintLocal Title IX ComplaintFederal Title IX ComplaintDepartment of Justice ComplaintEqual Employment Opportunity Commission (EEOC) FilingFreedom of Information Act (FOIA) RequestComplaint with a Funding AgencyComplaint with a Scientific SocietyCourt Filing / LawsuitOther
We do not provide emergency and are not a psychological conseling services. If you have urgent safety concerns, please contact 911, go to the nearest hospital or contact your doctor. If you or someone you love is in acute crises, please contact National Sexual Assault Hotline/RAINN 1-800-656-4673 or National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) to be connected to a trained counselor and additional local resources.

Please allow up to two weeks turnaround time as we are a volunteer staffed organization. If you do not hear from us within this time period, contact MeTooSTEM@gmail.com with a request for followup.

Please note, all responses are encrypted and data will be kept private. No
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