Client Information
Emergency Disclaimer: If this is an emergency or if anyone is in immediate danger, please call 911 or your local emergency services immediately. Do not rely on this service for urgent help in crisis situations. Please note that all information provided in this questionnaire is completely voluntary. While you are not required to share every detail, please be aware that the more thorough and complete your responses, the better we assessment we can provide for resources. Your information will not be sold or shared outside of the organization, but you are agreeing to the distribution of information to resources within For Safer Spaces and its volunteers. Additionally, it's important to understand that we are not emergency services and, we cannot guarantee specific services.
First name
Last name
Email
Phone Number
If not self-reporting: What is the name of the tenants/homeowners?
Address
What is the situation you are reaching out regarding? (How many people live in the home, are there children, pets, have you interacted with the resident, etc)
Please check the box if any of these situations apply - these are for the safety of our volunteers and does not disqualify or impact qualification for services:
Does the property appear vacant?
Are there any signs of dangerous activity (drug use, aggressive pets, aggressive behaviour, etc)
Are there concerns the home could be structurally unsound?
Is there a possibility of pests (rodents, bed bugs, cockroaches, etc)
Have utilities been disconnected?
Additional Concerns?
If any of the boxes above are checked, please include more information, if known, below.
Do you have any photos of the property? Please include them below or email to info@ForSaferSpaces.com
Select a File
Terms & Conditions
**Terms and Conditions for Intake Form** **1. Data Sharing and Storage**: By completing this intake form, you agree that the information provided will be stored on a secure cloud platform and will be accessible to volunteers of "For Safer Spaces". This is to ensure efficient coordination and management of the services provided. **2. Confidentiality and Use of Information**: The information collected will not be sold or used for commercial purposes. It is gathered solely for the purpose of identifying areas in our community that require additional resources and support. Our data collection and use are not discriminatory in nature. **3. Volunteer-Based Services**: "For Safer Spaces" is a volunteer organization. While we endeavor to provide assistance, we cannot guarantee the availability or provision of services. Services offered are not free of charge. **4. Referral and Service Provision**: You may be contacted by businesses representing "For Safer Spaces" to provide referrals and affordable options. We also strive to connect individuals to free community resources when available. **5. Educational Outreach**: We may use the information provided to inform you of educational opportunities within the community that could be beneficial. **6. Limitation of Liability**: "For Safer Spaces" is not legally liable for any services accepted through our referrals. Any agreement for services is strictly between the client and the contractor/service provider. **7. Emergency Situations**: This service is non-emergent. If there is an immediate risk to health or safety, it is imperative to contact Emergency Services immediately. **8. Escalation of Services**: In cases where "For Safer Spaces" is concerned about the safety of a community member or a vulnerable adult, we may escalate the matter to include appropriate authorities to ensure the safety of all involved. **9. No Affiliation with Law Enforcement or Government**: We are not affiliated with the police department or any government entity. Our goal is not to prosecute or charge individuals based on reports received. Our primary objective is to connect community members with local services that can offer needed support. By submitting this form, you acknowledge that you have read, understood, and agreed to these terms and conditions.
I agree to the terms & conditions
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