Resilient Services Intake Form

Resilient Services Inc.

Client Intake Form
Today's Date

MonthDayYear
Date
Name

Last NameFirst Name
Pronouns

He/Him/HisShe/Her/HersThey/Them
Does client prefer to be referred to by any other name?
Address

Address

Street Address Line 2

City/State/CountyState / Province

Zip
Phone Number
Please enter a valid phone number.
Other Phone
Emergency Contact Number
Please enter a valid phone number.
Name/Relationship
Email
example@example.com
In an emergency can this person be contacted?

YesNo
:Client can be contacted

At HomeBy MailBy PhoneBy TextEmail
Is discretion required? Instructions?
Brief Presenting Problem/lmmediate Need/Current Situation
Household Composition - Children 18 and Younger
Child (1)

NameRelationshipDOB/Age/IEP
Child (2)

NameRelationshipDOB/Age/IEP
Child (3)

NameRelationshipDOB/Age/IEP
Child (4)

NameRelationshipDOB/Age/IEP
Child (5)

NameRelationshipDOB/Age/IEP
Child (6)

NameRelationshipDOB/Age/IEP
Children 18 and Younger Living Outside The Home
Child (1)

NameRelationshipLive Where?DOB/Age/IEP?M/F
Child (2)

NameRelationshipLive Where?DOB/Age/IEP?M/F
Child (3)

NameRelationshipLive Where?DOB/Age/IEP?M/F
Child (4)

NameRelationshipLive Where?DOB/Age/IEP?M/F
Date of Birth:
Age:
Primary Language Spoken
English Language

Read?Write?
Other Language

Read?Write?Other Language
Gender:

FemaleMaleTransgender-ID as FemaleTransgender-ID as MaleOther
Race:

Black/African AmericanNative Hawaiian/Pacific IslanderWhiteAmerican IndianOther
Client Living Situation:

On StreetShelterTransitionalGroup HomeDrug Treatment ResidenceShort Stay Substance Abuse ProgramPermanent HomeRentalOwn HomeOther
Living Arrangment:

Relations/FamliyTemporaryAlonePermanentOther Living ArrangementOther
Does client have temporary, unsafe, and/or inadequate house?

YesNo
Does client have a functional support system?

YesNo
If yes, please describe your support system:
What type of Medical Insurance do you have?

No InsuranceOther
Please share any medical issues/conditions/concerns:
Please share any medications you take:
Please share any medical issues/conditions/concerns:

YesNo
DOMESTIC VIOLENCE HISTORY:
Please describe any mental health diagnosis you may have:
Please describe any substance abuse/use/diagnosis/history:
DOMESTIC VIOLENCE HISTORY:
Date:

MonthDayYear
Date
Name:
Have you ever been in an abusive relationship?

YesNoNot Sure
Please explain relationship
Do you feel safe in your current living arrangement? Please explain why or why not:
Do you have any needs related to a current or recent domestic violence situation? Please explain:
Did your children witness the abuse? Please explain:
What type of abuse have you experienced?

PhysicalVerbalSexualFinancialPsychologicalStalkingOther
Perpetrator Information and Description:
Perpetrator Name:
Other Name:
Relationship to you
How long have you known each other:
Gender:
Date of Birth
Age:
Ethnicty

CaucasianAfrican American/BlackHispanicNative AmericanOther
Is the perpetrator the mother or father of your children? Please explain:
Do you have any children by the perpetrator? Please explain:
Are you currently living with the perpetrator? Please explain:
Perpetrator past criminal history:
Perpetrator current criminal history:
Are you and the perpetrator currently in a relationship? Please explain:
Have you and the perpetrator ever been in a romantic relationship? Please explain:
Are you and the perpetrator currently living in the same home? Please explain:
Do you feel you are currently in a safe place? Please explain:
Are your children currently in a safe place? Please explain:
Has the perpetrator ever threatened to kill you or attempted to kill you? Please explain:
Has the perpetrator ever threatened to kill the children or attempted to kill them? Please explain:
Has the perpetrator ever choked or strangled you or attempted to do so? Please explain:
Has the perpetrator ever threatened to kill themselves? Please explain:
Has the perpetrator ever been violent toward anyone else, pets, other family, etc.? Please explain:
Have you and/or the children ever received medical treatment resulting from an abusive episode? Please explain:
What was the action taken after an abusive episode?
Have you ever been in an abusive relationship in the past with someone else? Please explain:
Have you ever received domestic violence counseling? Please explain:
Was law enforcement contacted during the recent abusive incident?

YesNo
If yes, please provide the following information:

PoliceSheriffTribalCountyOther
Were pictures taken of the abusive incident/scene? Please explain:
Was a protective order issued?

YesNoI don't know
Who has a copy of the protective order?
What city/state/county was the protective order given to you?
Was the perpetrator arrested?

YesNoI don't know
Were any changes filed?

YesNoI don't know
Is the perpetrator in jail/prison/on parole/probation/home detection/other?
The following is a brief history of my relationship with the perpetrator:
The following is my current situation:
Do you need assistance obtaining?

Nutritious FoodClothingTransportationLegal ServicesEducation/TrainingEmploymentChild CareMedical CareHousingOther
Do you feel you could benefit from Domestic Violence services?

CounselingEducationCouple CounselingFamily CounselingCounseling for your childrenEtc
Information Release

To release informationTo receive informationTo release and receive information
Records and the Information

To:From:Type of Information Given
I acknowledge that the type of information to be released and the period of time for which the information has been requested has been fully explained to me. I am signing this consent freely and voluntarily. I understand that I may withdraw my permission in writing at any time otherwise. this consent will expire within 2 years from the date. I understand there are some situations that Resilient Services will be mandated to keep this release in place such as subpoena by court, etc. I understand services are not contingent upon my decision concerning authorization for release of information.
Client Name
Client/Guardian Signature

Clear
Date

MonthDayYear
Date
Address:
Zip
Phone Number
Please enter a valid phone number.
Other Number
Please enter a valid phone number.
Email
example@example.com
Should be Empty:

Resilient Services Inc.

Household Composition - Children 18 and Younger

Children 18 and Younger Living Outside The Home

DOMESTIC VIOLENCE HISTORY:

DOMESTIC VIOLENCE HISTORY:

Perpetrator Information and Description: