• Support Group

    Support Group

  • Participation in A Safe Places' Supportive Services is Voluntary. Receipt of Supportive services under the FVPSA is voluntary. No condition will be applied to receipt of emergency shelter services.

  • BASIC INFORMATION

  • Format: (000) 000-0000.
  • Exp Date
     / /
  • Exp Date
     / /
  • Returning ASP Client?
  • Sexual Orientation
  • Gender
  • Education

  • *Employment: Currently Employed? ( )Yes ( ) NoOccupation:

  • Currently Employed?

  • Emergency Contact

  • Format: (000) 000-0000.

  • DOMESTIC VIOLENCE HISTORY AND ASSESSMENT

  • What is your relationship to the abuser?
  • Are there any children in common with the abuser?

  • LETHALITY ASSESSMENT

  • Type of abuse experienced
  • Date of the last incident
     / /
  • Were you hospitalized for physical abuse?
  • Are you in a safe place?
  • Does this person own or possess a firearm?
  • Is there a police report or restraining order on the abuser?
  • Is/was this person incarcerated for the abuse?
  • Date incarcerated, if applicable
     / /
  • Release date, if applicable
     / /
  • Next court date, if applicable
     - -
  • Past history of domestic violence?

  • LEGAL HISTORY

  • Have you ever been arrested?
  • Date of arrest
     / /
  • Are you on parole/probation?
  • Have you ever been ordered by the court to participate in mandated counseling or classes?
  • Are you currently involved in any kind of litigation or legal dispute?

  • MENTAL HEALTH HISTORY

  • Are you currently obtaining therapy such as individual or group therapy?
  • Are you currently experiencing depression/suicidal thoughts?
  • Have you recently been to a psychiatric hospital or day treatment center?
  • Are you currently on any psychotropic medication?

  • PHYSICAL HEALTH HISTORY

    Current physical health history or treatment (include present medical information and any accommodations if needed)
  • Are you currently on medication(s) for physical symptoms?

  • SUBSTANCE USE HISTORY

  • Have you recently been to an addition rehabilitation or recovery center?
  • Current substance use (i.e. street, OTC, non-RX pharma) or alcohol use?

  • ABUSER INFORMATION

  • Format: (000) 000-0000.
  • Date of Birth
     - -

  • Vehicle Information

  • Substance Use History

  • Does this person use drugs and alcohol?
  • Is the person currently seeking treatment?

  • Legal History

  • Has the person been arrested for abuse?
  • Do they have a history of arrest(s)?
  • Is person on parole/probation?
  • Is person currently involved in any kind of litigation or legal dispute?

  • Goals for Therapy at A Safe place

  • Date
     / /
  • Should be Empty: