Intake Application Form

Client Name

First NameLast Name

Date of Birth

Date

Cellular Number

Format: (000) 000-0000.

Does the offender know your address?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Offender Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Relationship to Offender

example@example.com

Date of Birth

Date

Male or Female

Offender Phone Number

Format: (000) 000-0000.

Are you currently living with the offender?

If yes do you have another place you can go where you can be safe?

Are you asking for exclusive use of the dwelling where you are living?

Are there any children in common with you and the offender if so list their Full Names, Date of Birth and Schools.

Do you feel the offender will hide? Abuse or harm said minor children?

Would you and the children be in danger if an Injunction of Protection is not issued to you?

Are you a victim of

The last episode of abuse took place

Specific Date

Describe the last incident of abuse:

YesNo

Does this person has an alcohol problem?

NOTICY OF PRIVACY ACT RIGHTS

Pursuant to the Privacy Act 10 U.S.C. 8013, all personal information provided to Survivors With A Testimony(S.W.A.T.) by way of any Board Member shall be held in confidence at all times and only shared with outside agencies and organizations that serve to assist the Client. This agreement signed by the Client shall serve as his or her authorization to share protected information with other agencies and organizations, only for the direct purpose of assisting the Client in his or her case through Survivors With A Testimony.

Required by Law. S.W.A.T. Caregiver Case Managers will disclose protected information when required by law in any; but not limited to, of the following situations:

• Reporting child abuse or neglect

• Court ordered

• Legal duty to warn or take action regarding imminent danger to others

• When client is a danger to self or others, or gravely disabled • When required to report certain injuries

Fundraising. S.W.A.T. may contact clients as part of its fundraising activities.

Emergencies. In life threatening emergencies, S.W.A.T. staff will disclose protected information necessary to avoid serious harm or death.

Client Authorization or Release of Information. S.W.A.T. may not use or disclose your protected information in any way without a signed authorization or release of information from you, except for the use in obtaining outside services; including but not limited to, mental health counseling, legal assistance, temporary housing and/or emergency shelter assistance. The authorization or release may be revoked by written request only. The revocation will apply upon receipt of notice in writing.

Copy of this Notice. You have a right to obtain another copy of this Notice upon written request.

___ Yes Client Agreement___ No Client Agreement___ Yes Notice of Privacy Right___ No Notice of Privacy Right___ Yes Welcome Letter and copies of all signed documents__ No Welcome Letter and copies of all signed documents

Signature

Signature Date

Date

Case Manager Signature & Date

SWAT Application