Domestic Violence Client Intake Form
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1 Domestic Violence Client Intake Form Date: Client ID: Client Name: DOB: Petitioner s Place of Birth Race Address: City State Zip Tel. No. Alt. No. Name/Relation of Contact Person Does the person who you are filing against know this address? [ ] yes [ ] no Employer Employer s address Tel. No. Ext. Does the person who you are filing against know where you work? [ ] yes [ ] no Is the person you are filing against aware of another place you frequent? [ ] yes [ ] no Name of place Address What is your relationship to the person who you are filing against? [ ] Married [ ] Divorced [ ] Dating (if so, how long) [ ] Boyfriend [ ] Former Boyfriend [ ] Intimate Partner [ ] Girlfriend [ ] Former Girlfriend [ ] Other) please specify) Are you currently living with the person you are filing against? [ ] yes [ ] no If yes, do you have an alternative place to stay tonight? [ ] yes [ ] no Are you requesting the exclusive use of the dwelling where you are living with the person that you are filing against? [ ] yes [ ] no
2 Are there any children in common with the person you are filing against? [ ] yes [ ] no Children s Name Date of Birth If yes, are the children currently residing or staying with the person you are filing against? [ ] yes [ ] no Do you fear that the respondent will abuse, remove, or hide the minor children? [ ] yes [ ] no Would your children be in danger if an Injunction for Protection is not issued to you? [ ] yes [ ] no If yes, please explain. Are you a victim of: [ ] verbal abuse [ ] psychological abuse [ ] sexual abuse [ ] physical abuse [ ] stalking The last episode of abuse took place: [ ] This week [ ] Last week [ ] A month ago [ ] Three months ago [ ] Six months ago [ ] One year ago [ ] More than one year ago [ ] other Specific date of last incident: Briefly describe the last incident of abuse:
3 The following information requested is for the person you are filing against: Name [ ] Male [ ] Female Birth Date Is Respondent known by a nickname or alias? Does this person own, possess, and/or is known to possess a firearm? [ ] yes [ ] no [ ] do not know If yes, what type(s) Has Respondent threatened to use firearm against you? [ ] yes [ ] no Does this person have a drug problem? [ ] yes [ ] no [ ] do not know Does this person have an alcohol problem? [ ] yes [ ] no [ ] do not know Does this person have a history of clinically diagnosed mental health problems? [ ] yes [ ] no [ ] do not know How long have you known this person (date)?
4 NOTICY OF PRIVACY ACT RIGHTS Pursuant to the Privacy Act 10 U.S.C. 8013, all personal information provided to Healing Household 6 by way of any Board Member or Caregiver Case Manager shall be held in confidence at all times and only shared with outside agencies and organizations that serve to assist the Client. This agreement signed by the Client shall serve as his or her authorization to share protected information with other agencies and organizations, only for the direct purpose of assisting the Client in his or her case through Healing Household 6. Required by Law. HH6 Caregiver Case Managers will disclose protected information when required by law in any; but not limited to, of the following situations: Reporting child abuse or neglect Court ordered Legal duty to warn or take action regarding imminent danger to others When client is a danger to self or others, or gravely disabled When required to report certain injuries Fundraising. HH6 may contact clients as part of its fundraising activities. Emergencies. In life threatening emergencies, HH6 staff will disclose protected information necessary to avoid serious harm or death. Client Authorization or Release of Information. HH6 may not use or disclose your protected information in any way without a signed authorization or release of information from you, except for the use in obtaining outside services; including but not limited to, mental health counseling, legal assistance, temporary housing and/or emergency shelter assistance. The authorization or release may be revoked by written request only. The revocation will apply upon receipt of notice in writing. Copy of this Notice. You have a right to obtain another copy of this Notice upon written request.
5 I acknowledge that I have been given/offered a copy of the following: Yes No Client Agreement Yes No Notice of Privacy Rights Yes No Welcome Letter and copies of all signed documents Client Signature Printed Name Date Caregiver Case Manager Signature Printed Name Date *Officer Approval: (initials) (date)
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