Extended Family US

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Changing Lives for a brighter future

HELP IS ON THE WAY

Extended Family US knows your pain, and we are here to tell you that your suffering and fear is over.  If you are ready for help, then we are here for you.

How our plan works.

Once you are accepted into our program, the first step is to leave. 
We will provide the neccessary transporation, shelter, and any other assistance that you and your child(ren) will need to be in a confidential safe enviornment.

You must be willing to relocate for a short period until the proper steps have been taken to ensure your safety.  Counceling/Therapy is available to you and your child(ren) to help you through this process.  Remember, you are not alone.

If you are ready for a change or want to speak with a representaive, please fill out the intake form below to get started.  There is no cost for this service, because saving your life and the lives of your child(ren) is priceless.


Remember, we cannot help you if you are not willing to take this first step.
 
Crisis Intervention
Advocacy
Spiritual Guidance
Education (Academic)
Community Education
Referrals
Counseling and Case Management
Support Groups
Referrals
Job Readiness
Family Life Education
Life Skills Training (LST)
Prevention Education
Youth Awareness
Transitional and Permanent Housing

Intake Form

If you are in need of assistance, please fill out this form. Someone will contact you as soon as possible.

Confidentialty Statement

All information received will remain confidential.As an applicant for our assistance/services, upon submitting this form you agree to the following statement: I understand that I am seeking or inquiring about assistance for the services provided by Extended Family US. I hereby release, indemnify and hold harmless Extended Family US, its officers, volunteers, successors, assigns, legal representatives, organizers, sponsors and supervisors of its activities, from any and all claims, causes of actions and liability arising from or in anyway connected with the assistance I receive from Extended Family US. I understand that I am expressly assuming all risk, including but not limited to all risk of injury, associated with my participation in the programs and services offered by Extended Family US or in Extended Family US activities conducted off-site.

In Case of an life threatening emergency

In case of a life threatening emergency, please LEAVE THE DANGEROUS ENVIORNMENT IMMEDIATLY AND DIAL 911.

Name or Alias/Nickname*

Best phone number to reach me (include area code)

Email Address*

Best Time to contact me*

Best Way to reach me

Phone
Email

City*

State

Zip Code*

Employment Status

Employed
Un-employed
Self Employed

In some cases, relocation is necessary. Are you willing to relocate?

Yes
No

Do you have children

Yes
No

Women seeking our services may experience some of these issues. If any of them apply to you, please check all that apply.

I am being physically abused
My child(ren) are being physically abused
I am being sexually abused
My child(ren) are being sexually abused
I am being held hostage
I feel my life is in danger
I feel the life/lives of my child(ren) are in danger
I cannot leave the abusive enviornment because I have nowhere else to go
I cannot trust anyone to assist me without my abuser finding me
I cannot leave because I am finacially dependant upon my abuser
I have tried to leave before
This is my first time trying to leave

I am seeking assistance from Extended Family US because:*

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