Intake Form

freeDimensional's Distress Services Intake Form

*(denotes required field)

First Name: *

Last Name: *

E-Mail Address: *

Date of birth (m/d/year) *

Sex *

Address *

Contact phone numbers (at least one) *

Country(ies) of citizenship *

Current location *

Languages spoken *

You are applying for which of the following?

Creative Safe Haven

Creative Resistance Fund

What services / resources are you in need of?

Psychosocial

Legal

Medical

Employment

Education

Housing / Food / Clothing

Professional Development

Community Engagement

Other

Case Information

What is(are) your area(s) of work? Please describe your latest projects.

Are you member of any organization, academic institution or professional association? If so, please describe it's mission or main focus of work, provide address, phone number, email, and name of the person accountable.

Are you currently employed? If so, please provide your employer's contact information if relevant to your situation.

Please describe your current situation.

Are you facing persecution as a result of your work? (threats, attacks, harassment, arrests, socially marginalized, blacklisted, etc.) Please give specific examples, with dates if possible.

Is the persecution you are now facing related to aspects of your personal identity? (For example: race, class, ethnicity, gender, or sexual orientation.) If so, please explain.

Please state your reason for requesting freeDimensional's assistance and give a detailed account of your needs.

Have you been in touch with other organizations about your situation or sought other sources of support? If so, which ones?

If this request is urgent, please explain why.

Provide contact information for at least 2 sources that can verify your story.

For any additional information you which to provide please use the space below.

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Intake Form

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