Safe space registration form

Name

Last name

Gender?*

Male

Female

Other

Age*

Your email*

Phone number*

Location?*

Are you able to make money?*

Yes

No

On a scale 1 - 10 how can you rate your emotions / feelings?*

Pease list 10 things that bothered you when you were growing up. Please do not include issues or situations that are happening now*

How can we assist you?*

How urgent is your situation?*

Critical

Manageable

What's the best commutation for you right now?*

Direct call

WhatsApp call

Google meet

Which time slot are you mostly available ?*

9 am - 10:30 am

2pm - 3:30

7pm - 9pm

Thank you for registering with Safe Space. We will contact you soon as we go through your form. Note: safe space is 100% free and protects your privacy, your personal information and everything you share with us is completely confidential*

I Understand

“There is hope, even when your mind tells you there isn't.”