Add Submission - Vela Advocacy Management

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Request for Services

Details for Request

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Thank you for reaching out to the Gulf Coast Center for Nonviolence for assistance. Please answer the following questions and an advocate will be in touch soon to set up services with you. This portal is only monitored Monday - Friday between the hours of 8 am - 4:30 pm. If you need immediate assistance, please contact our crisis line at 228.435.1968. If you are in danger, please call 911.

First and Last Name *

Date of Birth *

What is your phone number? *

Is this number safe to call and/or leave a message? *

Yes
No

What is the best time of day to contact you? *

What services are you interested in learning more about? *

Emergency domestic violence shelter program
Counseling - Adult
Counseling - Child
Court Advocacy - An advocate to accompany you to court or assist with non-attorney required legal services
Civil Legal Services - Attorney assisted divorce, child custody, or other legal matter.
Accompaniment to law enforcement interview
Housing Programs
Sexual Assault--Rape Crisis Follow-up/Case Management

What town do you currently live in? *

Have you experienced any of the following? *

Domestic Violence
Sexual Assault
Childhood Sexual Abuse
Sex Trafficking
Loved One Murdered

How did you hear about our services? *

Please tell us a little about what brings you to us for services. *

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