Counseling Referral Form | LiveSafe Resources | A Community Free of Domestic Violence & Sexual Assault | Cobb County

Skip to content

24-Hour Crisis Line 770.427.3390
Espanol?
Donate

24-Hour Crisis Line 770.427.3390
Espanol?
Donate

Search for:

Learn
Get Help
- - - Safety
    - Resources
  - - Services
Get Involved
About
Events

Counseling Referral FormGreen Mellen2021-08-04T10:03:47-04:00

Counseling Referral Form

"*" indicates required fields

Form for people interested in individual counseling related to domestic violence, sexual assault or elder abuse.

Client’s Information

Name*

First Last

Safe Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County*

Primary Language*

Date of Birth*

MM slash DD slash YYYY

Disabled*

Yes

No

Type of disability

If possible please provide at least two safe phone numbers where you can be reached.

Phone 1

Phone 2

Is it okay to leave voicemail messages at these numbers?

Yes

No

Email*

What have you experienced?*

Domestic violence

Sexual Assault

Elder Abuse

Have you ever received services from liveSAFE Resources before?*

Yes

No

If so, when and what services?

Case Type

Sexual Assault

Domestic Violence

EA (Elder Abuse)

Abuser’s Information

Do you currently live with the abuser?*

Yes

No

Name

First Last

Date of Birth

MM slash DD slash YYYY

Relationship to client:

Date of last incident*

Your form will be sent to the counseling department email: counselingreferral@livesaferesources.org

© Copyright LiveSafe Resources, Inc.
All Rights Reserved.

Administrative Offices
48 Henderson Street
Marietta, GA 30064
770-427-2902
Temporary Protective
Order Office:
770.528.8024

Should you need to translate this site into another language:

Haga clic en el botón "Spanish" al pie de esta página para leer la información en Español.

24-Hour Crisis Line 770.427.3390

Learn
Get Help
Get Involved
About
Events