Valiant Hearts · Get Help Form

Personal Information

Name *

First Name

Last Name

Age *

Gender *

Race/Ethnicity *

American Indian/Alaskan Native

Native Hawiian or Other Pacific

Black/African American

Hispanic/Latino

White/Caucasian

Asian

Multiple Races

Other

Not tracked

Email

Verify Email

Phone *

(ex.000-000-0000)

Zip Code *

How did you hear about us? *

What is the safest way to contact you?

Text

Call

Email

All of the above

Are you now or have you ever worked in the following areas: Optional *

Exotic Dancing

Escorting

Adult Massage Parlors

Prostitution

Adult Films

Phone Sex Operator

Not Applicable

Other Sex Industry related work (optional)

Have you experienced any of the following? *

We understand this is sensitive but it does help us know how to best meet your needs and understand all of the types of abuse our women face.

Physical Assault (as an Adult)

Sexual Assault (as an Adult)

Sexually abused/assaulted (as a child)

Domestic and/or Family Violence

Human Sex Trafficking

Please list any known mental illness diagnosis including but not limited to: Depression, Anxiety, PTSD, Personality Disorders, etc. *

Are you interested in: *

Support Group

Mental Health Services

Case Management

Housing

Resources for other needs

Other Services

Questions/Comments:

If you're unsure whether your situation matches these categories, please comment above or contact us and a team member will be happy to discuss your situation. Cherished Helpline: 682-317-8720

Received Services (For office/staff use only)

This includes emotional support, resources, referrals, help with applications, etc.

Yes

No