Seek Help — The SafeHaven Campaign

I am seeking help.

Name

First Name

Last Name

Phone

(###)

###

####

Thank you so much for reaching out, we are so proud of you! Someone from our team will contact you shortly.

*Referrals must be made with the permission of the person needing help. Both the person making the referral and the person being referred must sign electronically at the bottom of this form.

I am making a Formal or Agency Referral…

Name of Agency and/or Person making the referral:

Phone number of Agency and/or Person making the referral:

(###)

###

####

Person or Agency Contact Email Address

Name of Participant Being Referred:

First Name

Last Name

Phone of Participant Being Referred

Please provide a phone number where you can be reached.

(###)

###

####

Participant Email Address

Please describe the reason for your referral:

Electronic Agreement

By electronically signing my name and selecting "I Agree," I understand and authorize the agency(s) listed, The SafeHaven Campaign and The Church United of West Virginia, to exchange the above information to receive services from SafeHaven.

Name of Participant (or Legal Guardian if Applicable)

Name of Person Referring Participant to The SafeHaven Campaign

Date of Referral:

Please enter the date of the referral submission.

YYYY

Electronic Agreement

I am seeking help.

I am making a Formal or Agency Referral…

info@safehavenwv.com