Support Request Form

Intake for Victims 2026

If you are currently experiencing stalking and looking for support, please complete the following form. All questions are optional but, will help us better serve you and provide you with appropriate feedback, resources, and tips moving forward.

All answers are confidential and will not be disclosed without your permission.

Disclaimer: We are NOT a legal, mental health, or medical provider(s). We are not providing advice, in such fields.

Contact information

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* 1. Name:

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* 2. What county in Maryland is the pursuit occurring?

Western, MD

Baltimore Region

Capital Metro

Eastern Shore

Southern, MD

Another State

Outside USA

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* 3. Phone number:

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* 4. Email address:

Contact preferences

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* 5. Preferred contact method (select all that apply):

Phone

Text

Zoom

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* 6. What are the best days to reach you?

	Early morning (8-10am)	Late morning (10-12pm)	Early afternoon (12-2pm)	Late afternoon (2-4pm)	Early evening (4-6pm)
Monday	Monday Early morning (8-10am)	Monday Late morning (10-12pm)	Monday Early afternoon (12-2pm)	Monday Late afternoon (2-4pm)	Monday Early evening (4-6pm)
Tuesday	Tuesday Early morning (8-10am)	Tuesday Late morning (10-12pm)	Tuesday Early afternoon (12-2pm)	Tuesday Late afternoon (2-4pm)	Tuesday Early evening (4-6pm)
Wednesday	Wednesday Early morning (8-10am)	Wednesday Late morning (10-12pm)	Wednesday Early afternoon (12-2pm)	Wednesday Late afternoon (2-4pm)	Wednesday Early evening (4-6pm)
Thursday	Thursday Early morning (8-10am)	Thursday Late morning (10-12pm)	Thursday Early afternoon (12-2pm)	Thursday Late afternoon (2-4pm)	Thursday Early evening (4-6pm)
Friday	Friday Early morning (8-10am)	Friday Late morning (10-12pm)	Friday Early afternoon (12-2pm)	Friday Late afternoon (2-4pm)	Friday Early evening (4-6pm)

Additional information

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* 7. Which of the following steps have you taken?

Started a Stalking Log

Engaged Law Enforcement

Filed for or obtained a Peace or Protective Order

Engaged the States Attorney's Office or Filed Charges

Other (please specify)

None of the above

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* 8. What type of support are you looking for?

Information about legal options

Resources for mental or physical health

Education & information

Community & volunteer opportunities

Other (please specify)

Support Request Form

Intake for Victims 2026

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* 1. Name:

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* 2. What county in Maryland is the pursuit occurring?

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* 3. Phone number:

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* 4. Email address:

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* 5. Preferred contact method (select all that apply):

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* 6. What are the best days to reach you?

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* 7. Which of the following steps have you taken?

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* 8. What type of support are you looking for?

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* 9. Provide a brief description of your experience and your reasons for contacting us.

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* 10. Are you interested in joining our email list?

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* 11. Where did you learn about us?

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* 12. Additional comments: