Intake Form Intake Form Updates First NameLast NamePhone/MobileDate / TimeAddressAddress Line 1CityStateZip CodeEmailGender Male Female Non-Binary Prefer Not To Say OtherRace/Ethnicity Black or African American White Hispanic or Latino Asian Native American OtherMarital Status Single Married Hispanic or Latino Divorced Widowed In a Relationship SeparatedAge1) What are your most pressing needs today? What parts of your life would you like to talk about first?2) How can we best serve you? Please share any information that you want us to know.3a) Have you made a safety plan lately? Yes No3b) Do you feel that it meets your safety needs? Yes No3c) Would you like to make a new one? Yes No4) Do you want to talk about any other concerns? Are you worried about the safety of your dependents, pets, or anyone else?5) Is there anything else you would like to tell us about people or things that have caused you harm? Please share that here.o talk about any other concerns? Are you worried about the safety of your dependents, pets, or anyone else?6) Beyond housing, do you have any other basic needs, money needs, or goals that you have to meet right away? Yes NoRelationship to abuser:Perpetrators NameDate and time of incident:Description of incident:Has law enforcement been involved? Provide details:Are there any restraining orders or protection orders in place?What is your current source of income?Is it safe to contact this number? Yes NoIs it safe to contact this email? Yes Nowhat is the preferred and safest contact?Optional File UploadChoose File Submit Form
