The Proxy — Intake Form

01 — Contact

How should we reach you? *

You may use a pseudonym. We only need a way to follow up with you.

02 — Delivery Format

How would you like the message delivered?

Written (letter, email, or message) Phone or video call In-person (Northern Virginia / DC Metro area) I'm not sure yet

03 — Service Tier

What level of support do you need?

Delivery Only — I know what I want to say, I just need it delivered Full Service — I need help developing the message and support throughout I'm not sure — I'd like to discuss

04 — The Situation

Who is this message for, and what is the relationship?

Ex: former partner, employer, estranged family member. You don't need to use real names.

05 — The Message

What needs to be said? *

Share as much or as little as you're comfortable with right now. We'll work through the details together if needed.

06 — Desired Outcome

What outcome are you hoping for?

Closure, accountability, a response, nothing at all — all valid.

07 — Urgency

How soon does this need to happen?

08 — Anonymity

Would you like to remain anonymous to the recipient?

Yes — do not disclose my identity No — they may know it's coming from me I'd like to discuss this option

09 — Anything Else

Is there anything else we should know?

Safety concerns, sensitivities, prior attempts to have this conversation — anything relevant.

If pricing is a concern, you're welcome to mention it — either here or in a follow-up. This line exists quietly for a reason.

By submitting, you agree that all information shared is handled with full discretion under The Proxy's service agreement.

Tell us what needs to be said.