Safety first: in immediate danger call 112 · Women Helpline 181 · Tele-MANAS 14416

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A confidential first step

Request Mediation

Share only what feels safe. Your request is encrypted before storage and is held for authorised AAWAJ PARIVAR internal review; this form does not contact your partner.

1. About you

Use a name you feel safe using. This form does not contact your partner.

Your name (or name we should use)

Mobile number (WhatsApp preferred)

City

Preferred language

2. About the situation

I am reaching out as

WifeHusbandParentSiblingFriendOther

Years of marriage

<11–33–77–1515+

Current situation

What would help most right now? (choose all that apply)

Talk to a psychologistUnderstand legal optionsMediation with my partnerFamily mediationNot sure, guide me

Is your partner aware and willing to join?

YesNot yetDon’t know

3. Safety & consent

Do you currently feel unsafe or face any physical harm?

YesNoPrefer to discuss on call

Your safety comes first.Please call 112 or 181. A live AAWAJ coordinator pathway must be configured before this site can make a private follow-up call; do not wait for this form in an emergency.

Best time to call

How this form is handled

Your submission is encrypted before it is stored in AAWAJ PARIVAR’s protected internal review system. It is available only to authorised AAWAJ PARIVAR team members through a sign-in-protected workspace.

This form does not contact your partner, create an emergency alert or guarantee a response time. Share only what is necessary. If you are in immediate danger, call 112 or Women Helpline 181.

I have read the Privacy Policy and agree that the details I submit may be stored in AAWAJ PARIVAR’s protected internal review system.

AAWAJPARIVAR

Before you end it, let it be heard.

A neutral space for clarity, dignity and safety.

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If you feel unsafe

Safety is the first step. Emergency 112 Women Helpline 181 Tele-MANAS 14416