F.A.I.T.H. Connection Center Inc- Intake and Assessment Form (Confidential)

F.A.I.T.H. Connection Center Inc- Family Violence Intake and Assessment Form (Confidential)

Your responses are confidential and will be used to better understand your needs and provide the appropriate services and support.
Date:*

MonthDayYear
Date
Personal Information
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Are you aged over 60 years old?*

YesNo
Last four of SSN:*
What is your gender?*

FemaleMalePrefer not to say
Race:*

African American/Black/IndigenousCaucasian/WhiteAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderAsianTwo or More RacesOther
Ethnicity:*

Hispanic or Latino or Spanish originNot Hispanic or Latino or Spanish origin
Marital Status:*

SingleDivorcedWindowedSeparatedMarriedCo-habitant
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Would you like to receive text messages or emails from the F.A.I.T.H. Connection Center Inc?*

Yes, I would like to receive text messages.Yes, I would like to receive emails.No, I do not wish to receive text messages or emails.
Number of children living with you?*
Did you witness abuse as a child?*

YesNo
If yes, type of abuse:

PhysicalVerbalSexualMental/EmotionalFinancialSpiritual
What is your highest level of education?*

Less than High SchoolHigh SchoolAssociate DegreeBachelor DegreeGraduate Degree
Are you currently employed or seeking employment?*

Employed Full-TimeEmployed Part-TimeUnemployedRetiredSeeking EmploymentNot Seeking Employment
Are you veteran?*

YesNo
Are you disabled (physical or mental)?*

YesNo
Are you an adult whom has been aged out foster care or a group home?*

YesNo
Assistance Request
What type of resources, support or services are you seeking from F.A.I.T.H. Connection Center Inc? (Check all that apply)*

Safety PlanningHousing Support (rent, utility or relocation)Emergency ShelterSocial ServicesLegal Assistance (Protective Order)Childcare AssistanceCounseling or TherapyFinancial AssistanceSupport GroupsLife CoachingEducationJob Training or Employment AssistanceSpiritual SupportSelf-Development CoursesHealth and Wellness SupportBasic Resources (food, clothing, etc.)Anger ManagementAbuser ResourcesOther: (Describe Below)
For Other selection, describe here:
Funding is limited... if we cannot provide these services or other need we will refer you to another agency to address those areas of need. All bills must be in the clien't name.
Abuser Information and Description
Gender:*

MaleFemale
Age or Age Range:
Race:*

African American/Black/IndigenousCaucasian/WhiteAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderAsianTwo or More RacesOther
Ethnicity:*

Hispanic or Latino or Spanish originNot Hispanic or Latino or Spanish origin
What is the relationship between the abuser and the victim?*

Boyfriend / GirlfriendHusband / WifeLiving with themFamily memberOther
Abuser's past criminal history:
Current & Past Situation(s)
Are you currently experiencing domestic violence?*

YesNo
Did you know that women and children are not the only victims of domestic violence. Men can also be victims of domestic violence?*

YesNo
What type of domestic violence have you experienced? (Check the most recent)*

I have not been the victim of domestic violencePushing or shoving (causing no injury)Pushing or shoving (with injury)Hitting, slapping punching causing injuryKickingPulling hairUsing a source of an object to hit youAttempt of strangulationBeen burntOther
Which of type of domestic violence are you experiencing now? (Main Primary)*

Sexual Abuse: This includes any form of sexual violence, coercion, or unwanted sexual acts.Spiritual Abuse: involves the manipulation or control of someone through the misuse of religious or spiritual beliefs and practices.Neglect: Withholding food, medical care, or shelter as a means of control or manipulation.Reproductive Coercion: This involves sabotaging birth control, forcing pregnancy, or pressuring the victim to have or not have children against their will.Physical Abuse: This includes hitting, slapping, punching, kicking, or any other physical violence.Stalking: Repeatedly following or watching someone in a way that causes them fear or distress.Isolation: Attempting to isolate the victim from friends, family, or any support systems, making them more dependent on the abuser.Verbal Abuse: Name-calling, yelling, insulting, and using words to belittle or control the victim.Emotional/psychological Abuse: This involves manipulation, threats, humiliation, or constant criticism aimed at undermining the victim’s self-esteem and mental health.Financial/Economic Abuse: This form of abuse occurs when an abuser controls the victim’s access to money or financial resources, limiting their independence. Examples include withholding money, limiting employment opportunities, or controlling how money is spent.Digital Abuse: Involves the use of technology to harass, stalk, or control a partner. It may include monitoring texts, social media accounts, emails, or using GPS tracking without consent, or sending threatening or manipulative messages online.Don't wish to discuss
If you are the victim, do you know where to go?*

Friend'sWomen's RefugeeOrganizationsPoliceSocial servicesChurch LeaderWith a trusted Family memberOther
Other:
Are you interested in spiritual support, prayer, or faith-based counseling?*

YesNoNot sure
Do you need help accessing any of the following basic resources? (Check all that apply)

FoodHygiene ProductsTransportationClothingHousing/ShelterMedical/Health ServicesMental Health SupportSubstance Use SupportFinancial AssistanceLegal AssistanceIncome/Benefits AssistanceSpiritual SupportOther: (Explain Below)
Other:
Safety and Emotional Support
Are you currently in a safe environment?*

YesNoNot sure
If no, do you need immediate assistance with safety planning?*

YesNo
Are you experiencing any immediate threats to your safety?*

YesNo
Do you feel that your current environment is emotionally and physically safe?*

YesNoNot sure
Do you have reliable transportation?*

Yes, my carYes, bus or public accessNoYes, family or friend
Are you experiencing any physical, medical, health-related needs or mental health challenges that we should be aware of?*

YesNoIf yes, please describe below:
Provide brief statement:
Have you been involved in any previous domestic violence shelter, support programs or services services?*

YesNo
What are your main goals or areas you would like to improve upon?
Provide brief statement:
Life Coaching & Personal Development

Would you be interested in learning more about or joining any of the following organizations for additional support and services? (Check all that apply)
Alisha Jackson Academy – Offers courses and coaching to empower personal growth and transformation.*

Yes, I would like more information on joining Alisha Jackson Academy.No, I am not interested at this time.
Divine Warrior Life Coaching – Provides life coaching and guidance to help you overcome challenges and achieve your goals.*

Yes, I would like more information on joining Divine Warrior Life Coaching.No, I am not interested at this time.
Alisha Jackson Ministries – Offers spiritual support, prayer, and healing through ministry services.*

Yes, I would like more information on joining Alisha Jackson Ministries.No, I am not interested at this time.
A Better Life Publishing Company – Helps individuals share their stories and experiences through books and publications.*

Yes, I would like more information on joining A Better Life Publishing Company.No, I am not interested at this time.
Are you interested in life coaching or self-development courses?*

YesNo
What areas of personal growth or healing would you like to focus on? (Check all that apply)

Time ManagementGoal SettingPersonal GrowthSpiritual DevelopmentHealing from TraumaBuilding Self-EsteemStress ManagementConfidence BuildingEmotional RegulationOther (Explain below)
Other:
Would you like to receive follow-up information via email or phone about the services provided by any of the above organizations?*

Yes, I would like to receive follow-up information.No, I prefer not to receive follow-up information.
Preferred Method of Contact:*

EmailPhoneEither is fine
Would you like to receive texts?*

YesNo
Feedback & Improvement
How would you rate the support you received from F.A.I.T.H. Connection Center Inc?*

ExcellentGoodNeutralPoorVery PoorOtherNot applicable
Do you feel that the team treated you with respect, kindness, and empathy?*

YesNoNot sure
Would you recommend F.A.I.T.H. Connection Center Inc. to someone else in need of domestic violence services?*

YesNoNot sure
Are there any improvements you'd like to see in the service?
How easy was it to find the information you were looking for?*

Very EasyEasyNeutralDifficultVery Difficult
Additional Information
Is there any other information that would be helpful for us to know in order to best support you?
Consent and Acknowledgement
F.A.I.T.H. Connection Center Inc. utilizes a variety of funding sources, including private donations and federal grants, to assist clients in need. To ensure that all applicants have an equal opportunity to receive funding, it is important that they answer all questions truthfully and meet program requirements. Providing false information in an attempt to obtain funding is strictly discouraged and may lead to penalties if any misrepresentation is discovered. The funds are allocated to support those who need them most, and it is essential that they are used appropriately. As a victim of violence, I am requesting assistance to help address the challenges of family violence. I affirm that the information I have provided is accurate to the best of my knowledge. I understand that federal funds may be used, and I acknowledge that penalties could apply if any misrepresentation is found.
By signing below, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that the purpose of this form is to help connect me with the services and resources that best meet my needs.
Signature*

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Thank You for Applying to F.A.I.T.H. Connection Center Inc.

"For I know the plans I have for you," declares the Lord, "plans to prosper you and not to harm you, plans to give you a hope and a future." – Jeremiah 29:11
We are grateful for your trust in us and for taking the first step toward healing and support. Your application has been received, and we are honored to be a part of your journey. Our team is committed to offering care, resources, and a safe space for you and your family.

As you continue seeking support, we encourage you to connect with other agencies and resources in your community. Each organization offers unique services, and by reaching out to multiple centers, you can better meet your needs and ensure a more comprehensive support system.

Your feedback is important to us and plays a crucial role in helping us improve the services we provide. If you need immediate assistance, please call 911. We will reach out to you as soon as we are available. For enrolled clients, you can email at Admin@FaithConnectionCenter.org.

May you find peace and strength as you continue your path toward recovery. We look forward to walking alongside you every step of the way. Thank you again for reaching out to F.A.I.T.H. Connection Center Inc.

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Office Use Only:

Approved Denied

Assistance
Reason for denial:
Revised 03/2025
Referral or Resource Provided:
Revised 03/2025
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F.A.I.T.H. Connection Center Inc- Family Violence Intake and Assessment Form (Confidential)

Personal Information

Assistance Request

Abuser Information and Description

Current & Past Situation(s)

Safety and Emotional Support

Life Coaching & Personal Development

Feedback & Improvement

Additional Information

Consent and Acknowledgement

Thank You for Applying to F.A.I.T.H. Connection Center Inc.