Intake | Speak Out Illinois LLC

Client Intake

Intake Form

First Name

Last Name

Phone

Mailing Street

Mailing City

Mailing State

Mailing Zip

I agree and authorize Speak Out Illinois LLC to electronically process and store my information to communicate on Referrals with Third Party Organizations and Groups. I understand that Speak Out Illinois LLC will not sell, loan, or share my information without my expressed consent.

I acknowledge that Speak Out Illinois LLC, in good faith, will not charge me for any services or resources at any time. I understand that Speak Out Illinois LLC has the right to refuse service to anyone at any time without notice for failure to comply with Our Terms of Service, Company Standards and Third-Party Agreements.

I understand that Speak Out Illinois LLC will report all Illegal Activity to Local Law Enforcement in its sole discretion and upon possible review by it's Counsel.

I acknowledge that Speak Out Illinois LLC will automatically report to Local Law Enforcement for:

Child Abuse
Sexual Assault/Penetration to a Minor
Gun Violence
Human Sex Trafficking
Self Harm
Harm to Others
Any Information relating to a Crime

Shall you have any questions, You may write to legal@speakoutillinoisllc.com

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