Confidential Support Intake for Survivors Template
This intake collects safe contact details, immediate safety concerns, and support preferences from survivors seeking help. Advocates use it to plan a safe, appropriate response.
When to use it
- A survivor is requesting support from an advocacy service.
- A hotline or community organization needs to arrange a safe follow-up.
- An advocate wants to understand language and support preferences before meeting.
- A survivor needs to share whether children also need support.
What it asks
- What name should we use?
- Phone number
- Email address
- What is a safe way to contact you?
- What days or times are safe to contact you?
- Are you in immediate danger or in need of urgent help right now?
- What kind of support are you looking for?
- Are children involved or in need of support?
- What language would you prefer to use?
- Do you have a preference for your advocate?
Why it should be encrypted
Contact details, immediate safety concerns, and information about children could put survivors at risk if exposed. Only authorized advocates who need the information should be able to read responses—not SealForm or anyone without permission.
Tips
- Explain that this form may not be monitored immediately, and show urgent-help options near the start.
- Ask only for details needed to provide support, and make sensitive questions optional where possible.
- Tell respondents how and when an advocate may contact them, and remind staff to follow their safe-contact instructions.