Space for Change - Intake Survey

This form is confidential. It is a way for you to introduce yourself to Space for Change's program staff, shared between Walnut Avenue and the Conflict Resolution Center, so that we can have a conversation about how our program can best support you and your current situation.

The only required questions are your legal name, contact info, and preferred contact method. Information about your current situation is helpful and gives our program staff a starting point, but it is optional and you do not need to provide more detail than you think is important for us to know at this time.

Space for Change is a non-crisis service. You should expect a member of our staff to reach out to you within a few days of you submitting this form, and no more than 1 week. You can read more about our program here.

Please note that this form is not for someone seeking domestic violence advocacy services.
Space for Change is only for our restorative justice and community education/accountability services. If you are experiencing domestic violence and would like support from an advocate, you may:

Contact Walnut Avenue's 24/7 domestic violence helpline at (866) 269-2559 to receive immediate assistance
Contact our main office M-F, 9am-5pm, at (831) 426-3062
Visit our office at 303 Walnut Avenue, Santa Cruz, during drop-in hours on M-F, 10am-1pm

1.Legal first and last name:(Required.)

2.Preferred name, if different from your legal name:

4.How did you hear about this program?

5.Please select the option that best describes your role in the situation you'd like to bring to Space for Change.

I'm someone who has been directly harmed by my partner, former partner, and/or family member.

I'm an ally or loved one of someone who's been harmed.

I'm someone who has harmed my partner, former partner, and/or family member.

I'm an ally or loved one of someone who's caused harm.

I'm not sure.

None of these apply to me.

6.Space for Change offers a few different categories of services. Which one seems to be most relevant or important to you and the situation you'd like to bring to us?

Healing circles. This brings together someone who's been hurt and their loved ones so that they can have a facilitated discussion about the harm that happened and what future support looks like. This does not involve the person who directly caused the harm.

Ally education. We offer no-cost education for allies and loved ones who are looking for training to be safer, more effective support people for the survivors in their lives.

Community accountability and peer counseling. A person who's harmed a partner and/or family member can receive support in learning how to make safer, healthier choices. The person who was harmed is not required to participate. This is not a certified batterer intervention program, anger management, or a diversion program.

I'm not sure which of these options would be best for me and I'd like to have a conversation with a program facilitator to discuss them in more detail.

7.What's going on for you? Please describe the situation that you'd like to bring to Space for Change. You may include as much detail as you think is helpful for us to understand.

This form is confidential, but if there is information that you'd rather discuss over the phone with a facilitator, please make a note of that.

8.To the best of your knowledge, approximately when did the most recent incident of harm occur? What happened?

9.What are your goals with Space for Change? If you're not sure yet, that's also okay.

10.Please provide at least one safe method of contacting you.(Required.)

Phone

11.How would you prefer to be contacted?(Required.)

Email (please make sure to check your spam folder if you don't see a response from us in your inbox within 7 days)

Phone call (please make sure your voicemail is turned on and is not full)

Phone text

I'm fine with any option.