Safety & Wellbeing | VLF Clinical Assessment

⚑ If you are in crisis or immediate danger, please do not wait for a form response.
Mental Health Crisis Line: +1 (721) 585-5556 — Available 24 hours
Police Emergency: 911 or +1 (721) 542-2222
Victorious Living Foundation: +1 (721) 524-8731

Your Information

First Name *

Last Name *

Email Address *

Date

Question A

Do you feel emotionally safe in your current situation?

Question B

Have you experienced verbal, emotional, or physical harm in any relationship?

⚠️ Important: If you are in immediate danger, please contact emergency services. VLF can connect you with crisis support resources — please let us know at your first session.

Question C

Are there any concerns about substance use affecting your wellbeing?

Additional Notes

Is there anything else related to your safety or wellbeing you'd like your therapist to know?

Your responses are strictly confidential and submitted directly to Dr. Nicole E. Francis Cotton.

✅ Thank you — your assessment has been submitted.

Dr. Nicole E. Francis Cotton will review your responses before your session.