Referral and Registration Form

YOUR healing starts by completing the form below. Begin by sharing the information for whomever is in need or wants support.

Confidentiality:We recognize we have access to sensitive and personally intimate information. When we at Family Survivor Network (FSN)  interact and engage in/with/around you, your young one, and family, we agree to hold all such information confidential and not disclose any, unless authorized by YOU; with written and oral permission, or unless in the need of an emergency. Information sharing may only be used for purposes related to the nature of your participation/interaction/engagement with FSN. Information may not be shared with anyone outside FSN spaces. Information shared stays, knowledge learned is taken. If YOU feel Family Survivor Network has breached your confidentiality, please immediately consult the Chief Executive Director. Code of Conduct and Guidelines:

Family Survivor Network promotes healing, which never occurs in isolation. It requires an environment of self-awareness, respect, and understanding. While we emphasize the need for free expression, we ask that people avoid intentionally saying or doing things with the direct intent to harm. This includes cruel language or triggering behavior that attacks one's character, emotional/mental state, or body. In the event that this does occur, we will facilitate a healing circle with those impacted to vocalize the harm done and identify the steps that need to be taken to rectify it. Our code of conduct demands and requires that each member of our space do the work to maintain our culture of peace and the consistent effort required to continue being our best selves. EVERYONE will be treated with respect and given the power to influence the nature of our social change work together! As an organization, we seek to unlearn biases, discrimination, disenfranchisement, helplessness and all forms of “isms.”  I understand and agree that Family Survivor Network (FSN) shall assume NO LIABILITY for any damage or injury to any person or property while he/she or my child/youth is participating in any and all services and programs. I give permission to Family Survivor Network Inc (FSN) to use photos, videos, testimonials and recordings for communication, marketing, and promotional needs. I understand that participation with Family Survivor Network is governed and contingent on organizational policy and approval.Under penalties of perjury I hereby affirm that the information provided herein is true and correct to the best of my knowledge, information and belief.

FSN Referral and Registration

* indicates required
/ /( dd / mm / yyyy )
Availability between morning and evening Tues-Sat
Organization name + contact information (number and email)
Including experiences, behaviors, emotions, and symptoms.
Program
Which program(s) would you like to participate in?
Needs
Do you currently see a Therapist/Psychiatrist?
Have you received services from FSN previously?
Are you receiving support or services elsewhere?
Are you willing to complete an impact statement?
Did your loved one have life insurance?
Any physical limitations, disabilities, barriers? *
Could hinder or prevent participation in programs/services
Employment *
You or anyone in your household and/or immediate family
Received contact from the criminal justice system? *
i.e. in regard your loss
/ /( dd / mm / yyyy )
/ /( dd / mm / yyyy )
Birth certificate, death certificate, SSN SS card, state ID