Crowned Diamond Voices Foundation – Confidential Survivor Intake & Emergency Housing Needs
This questionnaire is designed to help Crowned Diamond Voices Foundation understand the survivor's immediate safety, housing, transportation, financial, and stabilization needs so that appropriate assistance and referrals can be coordinated. **CONFIDENTIAL CLIENT FILE — NOT FOR PUBLIC DISTRIBUTION
Contact & Safety Information
Client Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred/Safest Method of Contact
*
Phone Call
Text
Email
Other
Preferred/Safest Method of Contact - Other
Contact Safety Restrictions
Date you fled your previous residence/situation
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date you arrived at your new current location
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently in a safe location?
*
Please Select
Yes
No
Unsure
Is your current location temporary?
*
Please Select
Yes
No
What date does your current temporary housing end?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many days of secure housing do you currently have remaining?
*
Do you believe the person you fled from knows your current location?
*
Please Select
Yes
No
Unsure
Immediate safety concerns Crowned Diamond Voices Foundation should be aware of
Housing Needs & Stability
Type of housing needed immediately
*
Emergency hotel/extended stay
Domestic violence shelter
Short-term transitional housing
Apartment
Rental home
Other
Type of housing needed immediately - Other
Greatest housing need right now
*
What you need to become independently housed
*
Approximate monthly rent you could sustain once stabilized
Funds available
Rows
Yes
No
Security deposit
First month's rent
Application fees
Utility deposits
Temporary hotel/extended stay
Have you identified any housing possibilities?
*
Please Select
Yes
No
Identified housing possibilities - property name(s)
Immediate basic needs
*
Safe temporary housing
Permanent housing
Security deposit
First month's rent
Application fees
Other
Immediate basic needs - Other
Most urgent needs #1
Most urgent needs #2
Most urgent needs #3
Time needed in emergency housing before transitioning to independent housing
Primary obstacles preventing independent housing
Specific assistance that would help you become safely and independently housed
What stability would look like for you over the next 30–90 days
Additional information about your current situation or immediate needs
Employment, Income & Transportation
Current employment status
*
Full-time employed
Part-time employed
Self-employed
Unemployed
Seeking employment
Other
Current employment status - Other
*
Current monthly income
*
Reliable access to income/funds
*
Please Select
Yes
No
Partially
Current financial resources available for immediate needs
*
Currently receiving benefits or assistance
*
SNAP
TANF
Social Security/SSI/SSDI
Unemployment
Child support
None of the Above
Other
Currently receiving benefits or assistance - Other
Are you currently seeking employment or additional income?
*
Please Select
Yes
No
If yes, what employment/income assistance would be helpful?
Do you currently have reliable transportation?
*
Please Select
Yes
No
Temporarily
Do you have access to a vehicle?
*
Please Select
Yes
No
Do you have a valid driver's license?
*
Please Select
Yes
No
Do you currently need transportation assistance?
*
Please Select
Yes
No
If yes, describe transportation assistance needed
Documents, Children, Pets & Support Network
Documents currently in your possession
*
Driver's license/state ID
Social Security card
Birth certificate
Passport
Banking information
Other
Documents currently in your possession - Other
Are any essential documents currently inaccessible or missing?
*
Please Select
Yes
No
If yes, which documents are inaccessible or missing?
Do you have children whose needs must be considered in your housing plan?
*
Please Select
Yes
No
Number of children
Ages of children
Immediate needs involving the children
Housing
Food
Clothing
School enrollment
Childcare
Other
Immediate needs involving the children - Other
Do you have pets whose housing or care needs must be addressed?
*
Please Select
Yes
No
If yes, describe type/number of pets and current need
Documentation related to the domestic violence situation
*
Police report(s)
Protective/restraining order
Court documents
Attorney documentation
Domestic violence advocate documentation
Other
Are you currently working with any advocate, shelter, attorney, law enforcement agency, or other organization?
*
Please Select
Yes
No
If yes, organization/contact information
Intake Completion
Client Signature
*
Client Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Crowned Diamond Voices Representative
*
First Name
Last Name
Date Intake Completed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Intake
Submit Intake
Should be Empty: