Help is on the Way!

Healing Assessment Questionnaire

Thank you for taking the time to share your journey with us. This questionnaire helps us understand where you are right now and what tools, guidance, and support will best help you feel safe, empowered, and grounded. Please take your time, and only answer the questions you feel comfortable sharing.

Well-Being & SafetyDaily Life & CopingGuidance & SkillsSupport NetworkGoals & Contact

Current Well-Being & Immediate Safety

This section helps establish your baseline emotional state and immediate support needs.

How are you feeling overall in your day-to-day life right now? (Check all that apply)*

On a scale of 1 to 5, how safe, stable, and secure do you feel in your current physical environment?*

Do you currently have immediate safety or legal concerns? (e.g., housing instability, active harassment, ongoing legal or custody proceedings)

Please answer the required questions (marked with *) to continue. You can always go back and change your answers.

In an acute crisis or immediate danger: call 911 or your local emergency services. National Domestic Violence Hotline — 800-799-7233 or text BEGIN to 88788. Free, confidential, 24/7.

Prefer to just send a note? Reach out directly →