Genie Safety FAMILY Home Genie Safety FAMILY Request Help – Genie Safety Hub Full Name Preferred Name Age Do you identify as Aboriginal or Torres Strait Islander? Yes No Pronouns Phone Number Email Address Contact Method Call Text Email Safe Time to Contact You Are you currently safe? Yes No Do you have immediate concerns for yourself or your children? Yes No Are there children involved? Yes No If yes, how many and what are their ages? Support Needed Safe accommodation – Emergency/Short-Term Accommodation Counselling or Trauma Recovery Support Supervised Contact Visits Enhanced Maternal & Child Health Support Safety Planning Men’s Behaviour Change Program or Positive Behaviour Coaching Other (please describe) Do you identify as Aboriginal or Torres Strait Islander? Yes No Preferred language / Interpreter needed? Yes No If yes, specify language: I understand that the information I provide will be kept confidential and only shared with my consent unless required by law. Send