Sign-Up To Get A Survivors’ Mentor

Free Abuse Help & Support Sign-Up Form

Please fill in the following form to sign up and get a Survivors’ Mentor. For more information before signing up, see Mentoring for Domestic Violence Survivors.

Your name (required)

Your email address (required)

Are you in an abusive relationship right now?

If yes, how long have you been involved in this relationship?

If you left an abusive relationship, how long ago did you leave? (required)

Which age range describes you?

What would you most like to talk about through your emails with a mentor?

Check every box to show you read and understand the statements. You are required to read and mark each statement to participate in this program.

 I will not ask my mentor for his or her phone number or address.

 I will give only my city and state to my mentor if I need help finding local help agencies.

 I will email the Mentor Supervisor at vajournalsmentorprogram@gmail.com immediately If my mentor is not a right match for me so I can be reassigned.

 If I participate in the private FaceBook with other clients, I will keep all information shared confidential.

We offer a private Facebook group for our clients. Currently, a Facebook private group's posts will not appear on your timeline. Messages from the group will appear on your Home stream, but you can set them to not appear there either. Further instructions are in the document files in the group.

If you use a different email for Facebook than you gave above and you want to be added to the support group on Facebook, please enter the preferred email address below:

Do you wish to receive periodic newsletters from our website?

How did you find this website? (required)

When you press the send button below, this page will not change. You will see a confirmation message below the send button (you may have to scroll down a line or two to see it). Our Mentor Supervisor will be in touch with you very soon.

Please visit the National Domestic Violence Hotline website or call the NDVH at 1-800-799-7233 or 1-800-787-3224 (TTY)to find help with domestic abuse & violence near you.