SAFE HOUSE APPLICATION FORM

IF YOU, AS THE APPLICANT ARE IN IMMEDIATE PHYSICAL DANGER CALL 911

If you need immediate, safe housing call:

Anchor of Hope 717-761-2933, Ext 114

Name

First Name

Last Name

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Checkbox

Are you currently safe?

Yes

No

Do you fear for your safety or the safety of your children?

Do you have a protection from abuse order against your abuser? Do you need assistance in getting one?

Do you have children? If yes, please list names and ages.

Do you have a vehicle? if yes, is ir registered and titles in your name? If no, whose name is it registered and titled?

What is their relationship to you?

If someone else owns the vehicle mentioned above

Are you employed? If yes, where?

There is no cost for safe houses, but do you have finances? Are you able to provide for personal needs?

Do you have personal need you are not able to provide for? If yes, please explain.

Any dietary needs?

Do you have a pet? If yes, what animal?

Do you believe there is a security risk for the safe house with your abuser? if yes, explain.

Does your abuser have a history of violence? If yes, please explain.

Does your abuser own weapons?

Please remember that it is extremely important that Safe House identities and locations remain safe and secure. Therefore, it is necessary for all information regarding Safe Houses to be confidential. If you are pursuing a Safe House with Anchor of Hope please share that information only with one or two individuals you trust completely and inform them not to share that information with anyone. This helps to ensure not only your safety, but also the safety of the Safe House hosts and any individuals who will be using the Safe House in the future.

Thank you for reaching out to Anchor of Hope, your application will be reviewed and someone will contact you within 24 hours.

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