Program Intake Questionnaire

You reached out.
That took courage.

Complete this confidential intake form and a member of our team will follow up with resources, referrals, and support — at no cost to you.

Your information is confidential. Sanctuary will not share your information with ACS, courts, the other parent, or any third party without your explicit written consent. Submitting this form does not create a legal relationship. We are not a law firm. When you get better, your children get better.

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Basic Information

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Recovery Status

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Family Court Matter

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Children

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Current Concerns

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Legal Representation

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Safety & Confidentiality

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Consent to Contact

I understand that Sanctuary for Change Foundation, Inc. is not a law firm and that submitting this intake does not create an attorney-client relationship. I consent to Sanctuary reviewing this intake for program eligibility and referral purposes. I understand that my information will not be shared with ACS, courts, or any third party without my explicit written consent.

Prefer to reach out another way?

You can also contact Sanctuary directly by email at any time. You only need to share what you are comfortable sharing.

intake@sanctuaryforchange.org

SAMHSA crisis line (free, 24/7): 1-800-662-4357