{"id":1341,"date":"2012-11-05T16:59:10","date_gmt":"2012-11-05T16:59:10","guid":{"rendered":"http:\/\/freedimensional.org\/?page_id=1341"},"modified":"2014-04-12T13:48:42","modified_gmt":"2014-04-12T13:48:42","slug":"intake-form-twb","status":"publish","type":"page","link":"https:\/\/fd.artistsafety.net\/services\/distress-services\/intake-form-twb\/","title":{"rendered":"Intake Form (Theatre Without Borders)"},"content":{"rendered":"<p>If you have inconsistent internet access or for whatever reason are unable to input to this form directly, a downloadable version is available here: <a href=\"http:\/\/freedimensional.org\/wp-content\/uploads\/2011\/06\/fD_Distress_Services_Intake_Form_Sept2012.doc\">fD Distress Services Intake Form<\/a><\/p>\n<p><em>* Required<\/em><\/p>\n<div id=\"vfb-form-3\" class=\"visual-form-builder-container\"><form id=\"intake-form-in-association-with-theatre-without-borders-3\" class=\"visual-form-builder vfb-form-3 \" method=\"post\" enctype=\"multipart\/form-data\">\n\t  \t<input type=\"hidden\" name=\"form_id\" value=\"3\" \/><fieldset class=\"vfb-fieldset vfb-fieldset-1 intake-form \" id=\"item-vfb-69\"><div class=\"vfb-legend\"><h3>Intake Form<\/h3><\/div><ul class=\"vfb-section vfb-section-1\"><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-73\"><label class=\"vfb-desc\">All information uploaded on our intake form will be see only by freeDimensional staff and Distress Services case consultants and will remain entirely confidential. <\/label><\/li><div id=\"item-vfb-74\" class=\"vfb-section-div \"><h4>APPLICANT INFORMATION<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-radio  \" id=\"item-vfb-75\"><label class=\"vfb-desc\">Who is filling out this form? Are you:  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-75\" id=\"vfb-75-1\" value=\"Artist at Risk\" class=\"vfb-radio  required \" \/><label for=\"vfb-75-1\" class=\"vfb-choice\">Artist at Risk<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-75\" id=\"vfb-75-2\" value=\"Nominator\" class=\"vfb-radio  required \" \/><label for=\"vfb-75-2\" class=\"vfb-choice\">Nominator<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-75\" id=\"vfb-75-3\" value=\"Friend\/Family\" class=\"vfb-radio  required \" \/><label for=\"vfb-75-3\" class=\"vfb-choice\">Friend\/Family<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-76\"><label for=\"vfb-76\" class=\"vfb-desc\">If you are Nominator, Friend or Family member filling out this application please indicate your name here: <\/label><input type=\"text\" name=\"vfb-76\" id=\"vfb-76\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-77\"><label for=\"vfb-77\" class=\"vfb-desc\">Name of Applicant  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-77\" id=\"vfb-77\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-date  \" id=\"item-vfb-78\"><label for=\"vfb-78\" class=\"vfb-desc\">Date of birth  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-78\" id=\"vfb-78\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  required \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-checkbox  \" id=\"item-vfb-79\"><label class=\"vfb-desc\">Gender  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-79[]\" id=\"vfb-79-0\" value=\"Female\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-79-0\" class=\"vfb-choice\">Female<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-79[]\" id=\"vfb-79-1\" value=\"Male\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-79-1\" class=\"vfb-choice\">Male<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-79[]\" id=\"vfb-79-2\" value=\"Other\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-79-2\" class=\"vfb-choice\">Other<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-address  \" id=\"item-vfb-86\"><label class=\"vfb-desc\">Address <\/label><div><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-86[address]\" id=\"vfb-86-address\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-86-address\">Street Address<\/label><\/span><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-86[address-2]\" id=\"vfb-86-address-2\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-86-address-2\">Apt, Suite, Bldg. (optional)<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-86[city]\" id=\"vfb-86-city\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-86-city\">City<\/label><\/span><span class=\"vfb-right\"><input type=\"text\" name=\"vfb-86[state]\" id=\"vfb-86-state\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-86-state\">State \/ Province \/ Region<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-86[zip]\" id=\"vfb-86-zip\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-86-zip\">Postal \/ Zip Code<\/label><\/span><span class=\"vfb-right\"><select name=\"vfb-86[country]\" class=\"vfb-select  \" id=\"vfb-86-country\"><option value=\"\" selected='selected'><\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo (Brazzaville)\">Congo (Brazzaville)<\/option><option value=\"Congo\">Congo<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d\\'Ivoire\">Cote d\\'Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"East Timor (Timor Timur)\">East Timor (Timor Timur)<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia, The\">Gambia, The<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, North\">Korea, North<\/option><option value=\"Korea, South\">Korea, South<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palestinian Territory\">Palestinian Territory<\/option><option value=\"Palau\">Palau<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent\">Saint Vincent<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican City\">Vatican City<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Western Samoa\">Western Samoa<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><label for=\"vfb-86-country\">Country<\/label><\/span><\/div><\/li><li class=\"vfb-item vfb-item-email  \" id=\"item-vfb-80\"><label for=\"vfb-80\" class=\"vfb-desc\">Email Address  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"email\" name=\"vfb-80\" id=\"vfb-80\" value=\"\" class=\"vfb-text  vfb-medium  required  email \" \/><\/li><li class=\"vfb-item vfb-item-phone  \" id=\"item-vfb-81\"><label for=\"vfb-81\" class=\"vfb-desc\">Contact phone number  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"tel\" name=\"vfb-81\" id=\"vfb-81\" value=\"\" class=\"vfb-text  vfb-medium  required  phone \" \/><\/li><li class=\"vfb-item vfb-item-phone  \" id=\"item-vfb-82\"><label for=\"vfb-82\" class=\"vfb-desc\">Contact phone number 2 <\/label><input type=\"tel\" name=\"vfb-82\" id=\"vfb-82\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-83\"><label for=\"vfb-83\" class=\"vfb-desc\">Country(ies) of citizenship  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-83\" id=\"vfb-83\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-85\"><label for=\"vfb-85\" class=\"vfb-desc\">Current location  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-85\" id=\"vfb-85\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-84\"><label for=\"vfb-84\" class=\"vfb-desc\">Languages spoken  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-84\" id=\"vfb-84\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  \" id=\"item-vfb-88\"><label class=\"vfb-desc\">YOU ARE APPLYING FOR WHICH OF THE FOLLOWING  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-88[]\" id=\"vfb-88-0\" value=\"Creative Safe Haven (short-term long term residency)\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-88-0\" class=\"vfb-choice\">Creative Safe Haven (short-term long term residency)<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-88[]\" id=\"vfb-88-1\" value=\"Creative Resistance Fund (small emergency grant)\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-88-1\" class=\"vfb-choice\">Creative Resistance Fund (small emergency grant)<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-88[]\" id=\"vfb-88-2\" value=\"Services\/ Resources\" class=\"vfb-checkbox  required \" \/><label for=\"vfb-88-2\" class=\"vfb-choice\">Services\/ Resources<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-checkbox  \" id=\"item-vfb-87\"><label class=\"vfb-desc\">Services\/ Resources Needed <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-0\" value=\"Psychosocial\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-0\" class=\"vfb-choice\">Psychosocial<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-1\" value=\"Legal\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-1\" class=\"vfb-choice\">Legal<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-2\" value=\"Medical\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-2\" class=\"vfb-choice\">Medical<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-3\" value=\"Employment\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-3\" class=\"vfb-choice\">Employment<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-4\" value=\"Education\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-4\" class=\"vfb-choice\">Education<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-5\" value=\"Housing\/Food\/Clothing\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-5\" class=\"vfb-choice\">Housing\/Food\/Clothing<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-6\" value=\"Professional Development\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-6\" class=\"vfb-choice\">Professional Development<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-87[]\" id=\"vfb-87-7\" value=\"Community Engagement\" class=\"vfb-checkbox  \" \/><label for=\"vfb-87-7\" class=\"vfb-choice\">Community Engagement<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-89\"><label for=\"vfb-89\" class=\"vfb-desc\">Other services or resources needed <\/label><input type=\"text\" name=\"vfb-89\" id=\"vfb-89\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><div id=\"item-vfb-90\" class=\"vfb-section-div \"><h4>CASE INFORMATION<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-radio  \" id=\"item-vfb-91\"><label class=\"vfb-desc\">Please indicate the level of urgency of your request  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-91\" id=\"vfb-91-1\" value=\"Low\" class=\"vfb-radio  required \" \/><label for=\"vfb-91-1\" class=\"vfb-choice\">Low<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-91\" id=\"vfb-91-2\" value=\"On-going\" class=\"vfb-radio  required \" \/><label for=\"vfb-91-2\" class=\"vfb-choice\">On-going<\/label><\/span><span class=\"vfb-span\"><input type=\"radio\" name=\"vfb-91\" id=\"vfb-91-3\" value=\"Immediate\" class=\"vfb-radio  required \" \/><label for=\"vfb-91-3\" class=\"vfb-choice\">Immediate<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-92\"><label for=\"vfb-92\" class=\"vfb-desc\">Please state your reason for requesting freeDimensional&#039;s assistance and give a detailed account of your current situation.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-92\" id=\"vfb-92\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-93\"><label for=\"vfb-93\" class=\"vfb-desc\">What is(are) your area(s) of work? Please describe your latest projects as they relate to your current situation.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-93\" id=\"vfb-93\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-94\"><label for=\"vfb-94\" class=\"vfb-desc\">Are you facing persecution as a result of your work? (threats, attacks, harassment, arrests, socially marginalized, blacklisted, etc.) If possible, please give specific examples, with dates, locations, and key individuals involved.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-94\" id=\"vfb-94\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-95\"><label for=\"vfb-95\" class=\"vfb-desc\">Is the persecution you are now facing related to aspects of your personal identity? (For example: race, class, ethnicity, gender, or sexual orientation.) If so, please explain.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-95\" id=\"vfb-95\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-96\"><label for=\"vfb-96\" class=\"vfb-desc\">Have you been in touch with other organizations about your situation or sought other sources of support? If so, please tell us which ones and who your contact person there is.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-96\" id=\"vfb-96\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-97\"><label for=\"vfb-97\" class=\"vfb-desc\">Are you member of any organization, academic institution or professional association? If so, please describe its mission or main focus of work, provide address, phone number, email, and name of the person accountable.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-97\" id=\"vfb-97\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-98\"><label for=\"vfb-98\" class=\"vfb-desc\">Are you currently employed? If so, please provide your employer&#039;s contact information if relevant to your situation.  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea name=\"vfb-98\" id=\"vfb-98\" class=\"vfb-textarea  vfb-medium  required \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-99\"><label for=\"vfb-99\" class=\"vfb-desc\">For any additional information you which to provide please use the space below. <\/label><div><textarea name=\"vfb-99\" id=\"vfb-99\" class=\"vfb-textarea  vfb-medium  \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-131\"><label class=\"vfb-desc\">Instructions <\/label>Please be sure to click \u201cSubmit\u201d and wait until your browser finishes before going to another page. You may wish to print this page, or copy and paste your answers into an email to us, to ensure your submission is saved, in case it doesn\u2019t go through. Please contact us at distress@freedimensional.org if you need any help getting this form submitted to us. Thank you!\r\n\r\nPLEASE NOTE: All cases all carefully vetted by freeDimensional staff and volunteer Distress Services case consultants. 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