W.O.M.A.N., Inc. Interest Form_25-26

W.O.M.A.N., Inc. Interest Form
We ask everyone to fill out this form one time so we can provide you with services. Your information is kept confidential—no identifying details are ever shared outside our organization without your informed consent. These questions are for reporting and funding purposes only and help us better understand who is accessing our services.

This form is for survivors of domestic violence who are seeking services—advocates from outside organizations, friends, family, etc. cannot fill it out on their behalf.

If you could use some assistance filling out this form, please email appointments@womaninc.org or call our 24-hour support line (877) 384-3578.
Name*

First NameLast Name or Client ID (Client ID provided by staff)
Year of Birth*
Birth Year
Email (preferred)TextPhone call
Please Provide Contact Information For Your Preferred Method of Communication*
Phone number and/or Email
Chinese - CantoneseChinese - MandarinEnglishFilipinoRussianSpanishVietnameseOther
Address (Please use Cross Streets) i.e. "7th st. and Bryant st."*

Cross Streets

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the types of violence that you've experienced as an adult.

Mark ALL that apply
PhysicalEmotional/Verbal/Psychological AbuseStalkingFinancial AbuseUse of WeaponsTraffickingOther
YesNoUnknown
Race and Ethnicity

Which best describes your race/ethnicity? (Mark ALL check boxes that apply)
IndigenousAsianBlackLatinoMiddle Eastern/West Asian or North AfricanPacific IslanderWhite
American Indian/Native American (Specific Group: )Indigenous from Mexico, the Caribbean, Central America or South America (Specific Group: )Specifiy Indigenous Group
ChineseFilipinoJapaneseKoreanMongolianCentral AsianSouth AsianSoutheast AsianOther
AfricanAfrican AmericanCaribbean, Central American, South American or MexicanOther
North AfricanWest AsianOther
CaribbeanCentral AmericanMexicanSouth AmericanOther
ChamorroNative HawaiianSamoanOther
EuropeanOther
Gender Identity and Sexual Orientation
FemaleMaleGenderqueer/Gender Non-BinaryTrans FemaleTrans MaleDecline to AnswerOther
BisexualGay/Lesbian/Same-Gender LovingQuestioning/UnsureStraight/HeterosexualDecline to AnswerOther
Veteran and Disability Status
YesNo
YesNo
Homeless: ongoing situation, caller has no plans to relocate to stable, ongoing housing. Ex. living in a tent, on the street, under a freeway bypass, etc.Marginally Housed: time-limited with plans to relocate in the near future to stable, ongoing housing, typically in an unstable living situation. Ex. couch surfing, living in car, living in hotel, etc.
Family Size and Income
Single Headed FamilyDual Headed Family
Number of persons living in your family (including yourself):*
Estimated annual income:*
Income Certification
CalWorksCalFreshCash Assistance Linked to Medi-Cal (CALM)Cash Assistance Program for Immigrants (CAPI)County Adult Assistance Program (CAAP)Medi-CalRefugee Cash AssistanceSocial Security Disability Insurance (SSDI)Supplemental Security Income (SSI)Not Applicable
Public Benefits (mark here if you chose any option in the previous question)Payroll StubTax ReturnUnemployment BenefitsVeteran's BenefitsRental Assistance (e.g., Section 8 voucher)Placed in Foster CareSelf-Certified. Please explain
WOMAN, Inc. Peer/Group Counseling: FOR RESIDENTS OF SF ONLYSafe at Home ProgramWOMAN, Inc. Latinx Program: FOR MONOLINGUAL SPANISH SPEAKERS ONLYReferral to Cooperative Restraining Order ClinicOther
WOMAN Inc's support lineCROC restraining order intake workerOutside organizationPersonal connection (friend, family, co-worker)Other
Please share anything else you think we should know about your request for services.*

W.O.M.A.N., Inc. Interest Form

Please select the types of violence that you've experienced as an adult.

Race and Ethnicity

Gender Identity and Sexual Orientation

Veteran and Disability Status

Family Size and Income

Income Certification