Confidential Client Intake Form

Confidential Client Intake Form

Confronting Domestic Violence, Inc.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
How did you hear about us?*
Please Specify*
Confronting Domestic Violence, Inc. provides real time resources and referrals to real time victims & survivors. Please fill out this form so we are aware of your situation when calling you.
Do you understand the above statement?*

YesNo, I need clarity
Are you currently in a safe place?*

YesI/we are displacedNo, I/we need housing
Are children involved?*

YesNo
Please share the age of your children and if their daycare or school has been made aware of any safety concerns :*
Please share your current situation:*
Living with my abuser, in a shelter, staying in my car, sleeping on the couch at a friend’s house, receiving help from church, in transitional housing, etc.
Do you have a restraining order?*

YesI have an Emergency No Contact OrderIt's in processNoI have a police report number
Based on the above, please provide 3 bullet points of your critical needs. This will help me gather any information needed and be better prepared for our call.*
Please list any legal matters in this section :*
Restraining order, etc.
Are you currently working with an advocate or agency?*

YesNoMaybe, unsure

List any agencies or advocates your working with so we can potentially work together to help support you. Also list any programs you are participating in*

	Name or Agency	Status/Results	Contact info (if any)
1.
2.
3.
4.
5.
6.
7.
8.

Would you like to be added to our email list for future information?*

YesNo
Proprietary to Confronting Domestic Violence, Inc.
Should be Empty: