HAVEN - Facing Forward Application

Unfortunately, we are currently unable to accept new applications. Please check-back; we will reopen as funding allows.

Facing Forward is a HAVEN program launched jointly by Mass General and Mass Eye and Ear, provides cosmetic and dental reconstructive surgery and other medical procedures to help survivors of physical and emotional abuse move forward in their lives.

After you submit your request, a HAVEN representative will contact you within two weeks to ensure that your application is complete and to ask any preliminary questions.

Important note: Some questions on this form may appear or disappear based on your responses.

* indicates a required field.

Please call 911 if you are experiencing a medical emergency.

First name

Last name

Address line 1

Address line 2

City

State

Zip code

I (check all that apply)

Am in an abusive relationshipHave been in an abusive relationshipKnow someone who needs help

How would you like to be contacted? Please provide preferred contact information

PhoneEmail

Phone number

Is it okay to leave a voicemail message?

YesNo

Do you have any current safety concerns? If so, please describe.

Please provide a brief overview of your experience with domestic violence.

Please briefly describe your injury and how it happened.

Please describe to whom or what you turned to for support as you moved ahead as a survivor.

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HAVEN - Facing Forward Application

More Information

Unfortunately, we are currently unable to accept new applications. Please check-back; we will reopen as funding allows.