Disclaimer: Thank you for your interest in the Urban Specialists Help line. This form is used to collect information about new clients and for internal purposes only. The information you provide is confidential and will be treated accordingly. Only with consent will your information be shared
with other partners to provide you with the quick assistance that you deserve during this time.
Preferred method of contact:*
Are you currently employed?
Do you need assistance financial assistance?*
Do you have access to funds for basic needs(food, clothing, transportation)?*
Are you aware of victim compensation programs? ☐*
Would you like assistance applying for compensation?*
Do you need legal advice or representation?*
IMMEDIATE SAFETY AND MEDICAL
Are you in immediate danger?*
Do you need assistance obtaining a restraining order?*
Do you need emergency shelter?*
Do you or a family member need follow-up medical care?*
Emotional, Social, and Psychological
Would you like to speak to a counselor or therapist?*
Are you connected with any support organizations?*
Are you interested in joining a support group?*
Are you interested in mentoring services for your children?*
HOW DID YOU HEAR ABOUT US
Who referred you to the Urban Specialists Help Line?*
FAMILY AND SOCIAL INFORMATION
Are you the custodial parent or guardian of the child?*
Any family history of mental illness, substance abuse, or learning difficulties?
Thank you for providing your information. Please verify that all details discussed during our call are accurate as these will be used to process your request and tailor our services to your needs. If you notice any discrepancies later or have updates, please contact us immediately to make the necessary adjustments. It is essential that we work with the most accurate information to assist you effectively. We appreciate your attention to detail and look forward to serving you.
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