Intake
Name
*
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
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Angola
Anguilla
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Argentina
Armenia
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Australia
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The Bahamas
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Bulgaria
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Cambodia
Cameroon
Canada
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Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
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Faroe Islands
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Germany
Ghana
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Guyana
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Marshall Islands
Martinique
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Mayotte
Mexico
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Moldova
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
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Sao Tome and Principe
Saudi Arabia
Senegal
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eSwatini
Sweden
Switzerland
Syria
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Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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*
/
Month
/
Day
Year
Date
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S.S. #
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-
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Alternate Phone Number
-
Area Code
Phone Number
Email
example@example.com
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Driver License #
Employer
Gross Income (all sources) and frequency
Make of car
Model of car
Plate Number
Marital status
Single
Married
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**Fill out information for EACH PARTNER you have children with**
Children's Names
Other Parent's Name
Child's D.O.B.
Male/Female
Living with You?
1
2
3
4
Victim Information
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
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Germany
Ghana
Gibraltar
Greece
Greenland
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Guam
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Guinea
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Guyana
Haiti
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Japan
Jersey
Jordan
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Kenya
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Kosovo
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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Slovenia
Solomon Islands
Somalia
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South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
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Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
2nd Phone Number
-
Area Code
Phone Number
Age
Birthdate
-
Month
-
Day
Year
Date
Date Picker Icon
Work Phone-or-Company Name/City
Are you still in a relationship?
yes
no
Do you live together?
yes
no
How long in a relationship?
Restraining order?
current
prior
never
multiple times
Partner's Language
# of children with this partner?
# of children partner has from other relationships?
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Current Partner Information
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Birthdate
-
Month
-
Day
Year
Date
Date Picker Icon
Relationship to you?
Phone Number
-
Area Code
Phone Number
2nd Phone Number
-
Area Code
Phone Number
Work phone -or-Company Name/City
Are you in a relationship?
yes
no
Do you live together?
yes
no
How long in a relationship?
Restraining order?
current
prior
never
multiple
Partner's Language?
# of children with this partner?
# of children partner has from other relationships?
Former Partner Information
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Birthdate
-
Month
-
Day
Year
Date
Date Picker Icon
Phone Number
-
Area Code
Phone Number
2nd Phone Number
-
Area Code
Phone Number
Work phone-or-Company Name/City?
Are you in a relationship?
Yes
No
Do you live together?
Yes
No
How long in a relationship?
Restraining order?
Current
Prior
Never
Partners language?
# of children with this partner?
# of children partner has from other relationships?
Former Partner #2 Information
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Birthdate
-
Month
-
Day
Year
Date
Date Picker Icon
Phone Number
-
Area Code
Phone Number
2nd Phone Number
-
Area Code
Phone Number
Work phone-or-Company Name/City?
Are you in a relationship?
Yes
No
Do you live together?
Yes
No
How long in a relationship?
Restraining order?
Current
Prior
Never
Partners language?
# of children with this partner?
# of children partner has from other relationships?
Back
Next
Violence and/or Abuse:
Describe the incident that led YOU to be referred to this program- Do not detail the other person's actions:
Date incident occurred:
-
Month
-
Day
Year
Date
Date Picker Icon
Charge(s):
YOUR Actions
What was your reason for choosing those actions?
Was this your last incident towards this person?
Yes
No
When was your MOST RECENT hurtful behavior towards this person?
-
Month
-
Day
Year
Date
Date Picker Icon
Describe YOUR actions you chose at that time:
What was your reason for choosing those actions?
How many times have you been harmful towards this person?
How many OTHER partners have you been hurtful towards?
Who else have you hurt in a relationship?
Be sure to detail this person's information on the second page
How were you violent during those relationships?
Have you used alcohol or other drugs before or during any of your violence?
Yes
No
If "yes". what did you use?
Do you have any weapons?
Yes
No
If yes please answer the next two questions
If "yes" what kind?
If "yes" where are those weapons kept?
Have you ever threatened your current or ex-partner with a weapon?
Yes
No
If yes please answer next question
Have you ever used a weapon against her/him?
Yes
No
If yes please answer next two questions
If yes, when?
-
Month
-
Day
Year
Date
Date Picker Icon
If yes, Describe YOUR actions:
Have you ever threatened to kill or seriously harm your partner, ex-partner or others?
Yes
No
If yes please answer please answer next three questions
If yes, Who?
If yes, When?
-
Month
-
Day
Year
Date
Date Picker Icon
If yes, what did you say/threaten to do?
Have you ever spied on a partner by checking up on them?
Yes
No
If yes please answer the next two questions
If yes, When?
-
Month
-
Day
Year
Date
Date Picker Icon
If yes, How?
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Next
Substance Use/Abuse
Do you currently use alcohol?
Yes
No
If yes, how many times per month?
How much at each occasion?
Do you currently use illegal drugs?
Yes
No
If yes, What type(s)?
If yes, how many times per month do you use each of the above illegal drugs?
Have you abused alcohol or other drugs in the past?
Yes
No
If yes, When?
If yes, What kind(s) of substances have you abused in the past?
Are you currently in substance abuse counseling?
Yes
No
If yes, where?
If yes, for what reason?
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Next
Physical and Mental Health
Are you currently taking any prescribed medication for PHYSICAL reasons?
Yes
No
If yes, for what physical health reasons?
If yes, what medications do you take, and at what dosage?
Have you ever threatened or attempted suicide?
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
Date Picker Icon
What method(s) did you use/threaten?
Where you hospitalized due to suicide attempt(s)?
Yes
No
If yes, Where and for how long?
Have you had any thoughts of suicide?
Yes
No
If yes, when was the most recent?
-
Month
-
Day
Year
Date
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Do you have a current plan to harm yourself or others?
Yes
No
If so, what is your plan?
Are you currently in any form of counseling?
Yes
No
Name Of Counselor
First Name
Last Name
Name of Agency
Phone Number of Agency
-
Area Code
Phone Number
Address of Agency
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Are you on any medications for MENTAL health reasons?
Yes
No
If yes, for what reasons?
What medications do you take, and at what dosage(s)?
Who prescribes these medications?
Have you taken medications in the past for physical/mental health reasons?
Yes
No
If yes, what kind of medication(s) and for what reasons?
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Legal Information
have the police been called due to your actions?
If yes, why have the police been called? Please list dates and places for each offense.
Have you ever been charged with a crime?
Yes
No
What have you been charged with during your life? Please list dates and places for each offense.
Have you ever been incarcerated?
Yes
No
If yes, when/how long?
Are you on probation/parole?
Yes
No
When does it expire?
-
Month
-
Day
Year
Date
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Which courts?
Who is/are you P.O.'s?
Does you partner/ex-partner have a Family Protective Order/No Contact Order against you?
Yes
No
IF yes, when does it expire?
-
Month
-
Day
Year
Date
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What court is it out of?
What are the conditions on this order?
What is the reason this FPO/No Contact Order was placed against you?
Have you had an FPO in the past?
Yes
No
If so, how many?
1
2
3
4
5
6
7
8
9
10
What years were those orders in effect?
What were the reason(s) those orders were placed against you?
Have you violated any of those orders?
Yes
No
If yes, how many times?
1
2
3
4
5
6
7
8
9
10
How did you violate those order(s)?
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Child Information
Are you required to make child support payments?
Yes
No
If yes, what is the amount per week?
Are these payment voluntary or court required?
Voluntary
Court required
Are they deducted?
Have you been making these payments as required?
Yes
No
Do you have any involement with DHHR?
Yes
No
If yes, what is your case workers name?
What branch office?
*if you have an open CPS case, please provide a copy of your service plan ASAP*
What are the requirements of your service plan?
Has a child abuse report ever been filed on you?
Yes
No
If yes, What was the result of the investigation?
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Referal Information
How did you find out about CAV?
Who referred you to CAV?
I verify that the above information in this document is truthful and accurate, that I will inform CAV immediately if any of the above information changes or is updated in any way, and that I have had a chance to have my questions answered.
Your Name
First Name
Last Name
E-Signature
Clear
Todays Date
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Month
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Day
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Date
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