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
Format: (000) 000-0000.
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?
Are you currently in a safe place?
Are children involved?
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?
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?

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

Rows	Name or Agency	Status/Results	Contact info (if any)
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Would you like to be added to our email list for future information?
Do you consent to sharing your information with our partners (Other DV Providers)?
Proprietary to Confronting Domestic Violence, Inc.
Should be Empty: