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Family Violence Outreach Referral

PLEASE NOTE We currently have a ONE MONTH long waitlist. We will contact you as soon as we are able, if you are needing immediate supports please contact our 24/7 Crisis Line at 780-875-0966.


The Family Violence Outreach Program provides support to women affected by family/relationship violence; to promote safety and strengthen wellbeing for women and children. Services include one-to-one support, family violence information, safety planning, help with basic needs, community referrals. 


If you are having difficulty with this form, have questions, or would like to talk to an Outreach Worker directly, please call 780-808-5282 ext. 4001 or 4002 or you can email communityoutreach@sparklloydminster.ca

Have you been affected by family/relationship violence (past/present)?

Note The Family Violence Outreach program is specifically for women that have been affected by family/relationship violence. If the answer to this question is "no", please contact the Interval Home 24/7 crisis line (780-875-0966) to see if there is a program that better fits your needs.

Have you been affected by family/relationship violence (past/present)?
Yes
No

Do you want support with your experience of family/relationship violence?

Note The Family Violence Outreach program is specifically for women that are wanting support around their experience of family/relationship violence. If the answer to the above question is "no", please contact the Interval Home 24/7 crisis line (780-875-0966) to see if there is a program that better fits your needs.

Do you want support with your experience of family/relationship violence?
Yes
No
Birthday

Preferred Contact Method

Preferred Contact Method

Is it safe to leave a voicemail?

Is it safe to leave a voicemail?
Yes
No

Is it safe to text?

Is it safe to text?
Yes
No

Gender Identity

Best time to contact (ex. morning, afternoon, evening, etc.)

Are you currently living in the Lloydminster area or are trying to relocate to the Lloydminster area?

Please note that we currently only offer Outreach services to individuals who are living in, or are planning on living in, the Lloydminster area. This includes surrounding communities (ex. Maidstone, Lashburn, Kitscoty, Vermillion, Onion Lake, etc.)

Are you currently living in the Lloydminster area or are trying to relocate to the Lloydminster area?
Yes
No
Other

Are there any safety concerns for you or those around you that we should know about?

Supports needed, Check all that apply:

Supports needed, Check all that apply:

Are you filling this form out for yourself or are you from a referring agency (ex. RCMP, CFS, etc.)?

Are you filling this form out for yourself or are you from a referring agency (ex. RCMP, CFS, etc.)?
Self Referral - I am referring myself
Referral Agency
SPARK Foundation of Lloydminster white logo with transparent background.
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