Intake

Intake
Name *

First Name Middle Name Last Name Suffix

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birthdate *

Month Day Year
Date Date Picker Icon
S.S. #
Phone Number

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Email
example@example.com
Ethnicity
Driver License #
Employer
Gross Income (all sources) and frequency
Make of car
Model of car
Plate Number
Marital status

**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	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?
Do you live together?
How long in a relationship?
Restraining order?
Partner's Language
# of children with this partner?
# of children partner has from other relationships?

Current Partner Information

First Name Middle Name Last Name Suffix

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	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?
Do you live together?
How long in a relationship?
Restraining order?
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	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?
Do you live together?
How long in a relationship?
Restraining order?
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	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?
Do you live together?
How long in a relationship?
Restraining order?
Partners language?
# of children with this partner?
# of children partner has from other relationships?

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?
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?
If "yes". what did you use?
Do you have any weapons?
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?
If yes please answer next question
Have you ever used a weapon against her/him?
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?
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?
If yes please answer the next two questions
If yes, When?

Month Day Year
Date Date Picker Icon
If yes, How?

Substance Use/Abuse
Do you currently use alcohol?
If yes, how many times per month?
How much at each occasion?
Do you currently use illegal drugs?
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?
If yes, When?
If yes, What kind(s) of substances have you abused in the past?
Are you currently in substance abuse counseling?
If yes, where?
If yes, for what reason?

Physical and Mental Health
Are you currently taking any prescribed medication for PHYSICAL reasons?
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?
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)?
If yes, Where and for how long?
Have you had any thoughts of suicide?
If yes, when was the most recent?

Month Day Year
Date Date Picker Icon
Do you have a current plan to harm yourself or others?
If so, what is your plan?
Are you currently in any form of counseling?
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	Country

Are you on any medications for MENTAL health reasons?
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?
If yes, what kind of medication(s) and for what reasons?

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?
What have you been charged with during your life? Please list dates and places for each offense.
Have you ever been incarcerated?
If yes, when/how long?
Are you on probation/parole?
When does it expire?

Month Day Year
Date Date Picker Icon
Which courts?
Who is/are you P.O.'s?
Does you partner/ex-partner have a Family Protective Order/No Contact Order against you?
IF yes, when does it expire?

Month Day Year
Date Date Picker Icon
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?
If so, how many?
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?
If yes, how many times?
How did you violate those order(s)?

Child Information
Are you required to make child support payments?
If yes, what is the amount per week?
Are these payment voluntary or court required?
Are they deducted?
Have you been making these payments as required?
Do you have any involement with DHHR?
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?
If yes, What was the result of the investigation?

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

Month Day Year
Date Date Picker Icon
Should be Empty:

Intake

Violence and/or Abuse:

Substance Use/Abuse

Physical and Mental Health

Legal Information

Child Information

*if you have an open CPS case, please provide a copy of your service plan ASAP*

Referal Information

if you have an open CPS case, please provide a copy of your service plan ASAP