Domestic Violence Survivor Safe Housing Intake

Domestic Violence Survivor Safe Housing Intake — Form Fields

This nonprofit template includes 7 fields. Confidential intake form for survivors seeking safe housing and support services. Free to customize and use on ZenBuild.

• First Name Only (text, required)
• Safe Phone Number (text, required)
• Number of Children Accompanying (number, optional)
• Urgency of Need (dropdown selection, required) — options: Immediate (Tonight), Within 24 Hours, Within 72 Hours, Planning Ahead
• Services Needed (checkboxes, required) — options: Emergency Shelter, Legal Advocacy, Counseling, Children's Services, Financial Assistance
• Safe to Receive Calls from Us? (multiple choice, required) — options: Yes, No, Text Only
• Any Additional Safety Concerns to Share (long text, optional)