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Personal Information

Full Name:

Age:

Gender:MaleFemaleOther

Phone Number:

Email Address:

Preferred Method of Contact:PhoneEmail

Current Address:

City:

Country:

Incident Overview

Date of the Incident:

Location of the Incident:

Brief Description of the Incident:

Has the Incident Been Reported to the Authorities?YesNo

If yes, please provide details:

If no, would you like assistance in reporting it?YesNo

Current Condition and Needs

Areas of the Body Affected by the Burn:

Medical Treatment Received:YesNo

If yes, please provide details:

Current Physical Condition:

Rehabilitation and Support

Type of Rehabilitation Support Needed:Physical TherapyPsychological CounselingLegal AssistanceEmployment SupportVocational TrainingHousing/ShelterOther

Are you currently receiving any support from other organizations?YesNo

If yes, please provide details:

Are there any immediate needs or urgent assistance required?YesNo

If yes, please specify:

Privacy and Confidentiality

Would you like your information to remain confidential?YesNo

Can we share your story (anonymously, if preferred) with our partners?YesNo

Additional Information

Any other information you would like to provide?

Note: Your privacy and safety are our top priority. All information shared will be kept confidential and used solely to provide the support and rehabilitation you need.