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Survivor Qualification Form (Make Me Visible Sanctuary Application)

Introduction

Make Me Visible is a sanctuary for those battling chronic illness and systemic erasure: people denied protection, justice, or access to care because their situation was “too complex” or “not profitable” for traditional systems. This application ensures we serve those who most need a foundation for access to healing, protection, and leadership.

A. Personal Information
B. Your Story

1.Have you been scapegoated, targeted, or unsupported despite doing your best?

2.Briefly describe a time when you were denied protection, resources, or support in a critical moment of your life.

3.What is your current support system? (Select all that apply)

Other (please specify):

4.Have you been blamed for your circumstances by those who should have helped you?

5.Have you experienced being labeled “the problem” instead of receiving help?

6.What steps have you taken to try to change your situation or advocate for yourself?

7.Have you experienced institutional betrayal or erasure (workplace, family, medical, legal, etc.)?

8.Which institutions were involved?

Select all that apply:

9.Timeline of events

Please summarize the sequence of events and which institutions were involved.

10.What actions did you take to seek resolution?

Examples: filed complaints, reported to agencies, contacted professionals, requested institutional review

11.What happened after those steps were taken?

Examples: case closed, no response, redirected to another office, professional withdrew, investigation stalled

12.What consequences resulted from the situation?

Examples: financial losses, medical complications, employment disruption, housing instability, legal consequences

C. Chronic Illness & Medical Access

1.Have you been diagnosed with a chronic illness or complex health condition?

2.Have you been denied access to advance your recovery?

3.Have you sought out or advocated for better care, alternative solutions, or treatments, locally or internationally?

4.How are you currently supporting your chronic illness?

Other (please specify):

5.What documentation exists?

Examples: emails, reports, medical records, legal filings, internal complaints

6.Are you interested in being considered for innovative or advanced therapy programs through Make Me Visible?

D. Your blog

1.Make Me Visible exists to support patients and survivors who have been abandoned by every system. Please share your story and the systems where you have experienced dismissal, denial, or neglect.

I. Legal

II. Medical

III. Familial

IV. Social

2.Is there additional information you would like to share?

E. Affirmation
F. Book a Meeting

1.Would you like to book a confidential meeting or intake call with a Make Me Visible advocate to discuss your situation and explore your next steps?

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