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SAHC Services Request
If you are interested in receiving services at SAHC, please fill out this form. An advocate in your preferred office location will be in touch to schedule an appointment.
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* Indicates required question
Are you seeking services for yourself, a child, and an adult with legal guardianship?
*
I am an adult (18+) and seeking services for myself
I am a child (under 18) and seeking services for myself
I am a parent/guardian of a child (under 18) who is seeking services
I am a legal guardian of an adult (18+) who is seeking services
If you are under 18 and seeking services for yourself, please understand that we are required to contact your parent/guardian.
*
I agree
N/A
Your Name
*
Your answer
Your Phone Number
*
Your answer
Is it safe to leave a voicemail or send a text message?
*
Select all that apply.
It is safe to leave a voicemail at this phone number
It is safe to text this phone number
Please do not leave a voicemail or send a text message
Required
Your parent/guardian's name and phone number.
If under the age of 18 and requesting services, please provide your parent/guardian's contact information.
Your answer
Which office would you prefer to receive services at?
*
Wheeling Office
Benwood office
New Martinsville Office
Weirton Office
Other:
Is there anything else you feel would be beneficial for us to know?
Your answer
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This form was created inside of Upper Ohio Valley Sexual Assault Help Center.
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