Get Help Now
IF YOU ARE IN AN EMERGENCY SITUATION PLEASE CALL 911. IF YOU NEED IMMEDIATE ASSISTANCE YOU CAN CALL THE NATIONAL HUMAN TRAFFICKING HOTLINE AT 1-888-373-7888. FOR A NON-EMERGENCY SITUATION, YOU CAN FILL OUT THE FORM BELOW.
Sign in to Google to save your progress. Learn more
We are not a crisis resource. However, once you have completed this form someone will get in touch with you soon. If you are completing this over the weekend you can expect someone to follow up on Monday. Though we won't be able to meet all of your needs, we are hopeful that we will be able to connect you with the resources you need. Getting help is so brave! 
Name: *
Birthdate: *
MM
/
DD
/
YYYY
Where are you currently located and what is your living situation? (city, state and any other information you would like to include) *
Please check all that apply: *
Current Needs (check all that apply): *
Required
How can we contact you?: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Rescue Hill NCMC. Report Abuse
Google Forms