Request for Support Service Listing Organization Name*Please provide a 75-word description of your organization.*This description will display with your listing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Judicial District*County or Counties*Website URLPlease include https:// or http:// Program Type*Select one that best fits your organization Campus Community-based Culturally specific Child Advocacy Center Is this a confidential resource?* Yes No Do you have a dedicated staff or programming specific to serving the following populations?Select all that apply LGBTQIA Survivors Latinx Survivors Survivors with disabilities Immigrant/Refugee Survivors Asian Pacific Islander Survivors Native American/Indigenous Survivors Deaf & hard of hearing Survivors Undocumented Survivors Survivors with Intellectual and developmental disabilities N/A Languages you have bilingual/multilingual staff available to provide services in* ASL Amharic Arabic Burmese Chinese, Mandarin Chinese, Yue English French German Hindi Hmong Japanese Karen, Pa’o Korean Nepali Russian Somali Spanish Swahili Tagalog Tigrigna Vietnamese Other Services Offered*Select all that apply Support groups Individual Counseling Friends and Loved Ones support groups Legal Advocacy Case management (ongoing support) Protection order assistance Transportation assistance Food bank Hotel/housing vouchers Emergency Shelter Emergency financial assistance 24/7 crisis line 24/7 in-person response at hospital 24/7 in-person response at police agency Language Line 24/7 Support Line Phone Number(s)For counseling services, please indicate if your services are:*(select all that apply) Free Sliding Scale Accepts Crime Victim Compensation Accepts Health Insurance Contact Person*This information will not display publicly - this is for follow-up if we have questions regarding your listing First Last Contact Email*This information will not display publicly Contact Phone*This information will not display publicly Upload your logoRecommended size is 270 x 200Accepted file types: jpg, png, Max. file size: 50 MB. Δ
