Intake

Caller: Self Other

Date/Time: ________________________
If Other What is the relationship:
__________________________________

Client Information
Name: _____________________________
___________________________________
Other names used: ___________________
___________________________________

Age: _______
DOB: ___________________
Country Born: _______________________
Citizenship: _________________________

Emergency Contact:
Name: _____________________________
Relationship: ________________________
Phone number: _____________________

Address: __________________________ Phone Number:

__________________________________ ________________________ home
__________________________________ ________________________ cell
Clients Location (if not at home):______ Ok to call? Yes No
__________________________________
Does client feel safe there?:
Children: Yes No
Yes No N/A
If yes, list names, gender, DOB, location, and father:
Does client want to leave?:
__________________________________________________________________________
Yes No N/A
__________________________________________________________________________
Does client have a car? Yes No
__________________________________________________________________________

Language:
English: Yes No If yes,
English Vietnamese Cantonese Mandarin Chinese Japanese Thai
Spoken: Basic Intermediate Fluent
Lao Khmer (Cambodian) Hindi Urdu Punjabi Bengali Tamil Reading: Basic Intermediate Fluent
Telegu Nepali Arabic Greek Spanish Cape Verdean Creole
Written: Basic Intermediate Fluent
Haitian Creole Polish Russian Yiddish Italian German French Interpreter

used: Yes No
American Sign Language
Other: ___________________________________________

Self-Identified gender: Self Identified Race (check only one):
Ethnicity: Portuguese/Azores Laotian
female male White Black Asian
Indian Sub Continent Latino Vietnamese
male to female transgendered
American Indian/Alaskan Native
Middle Eastern Cape Verdean Creole
female to male transgendered
Native Hawaiian or other Pacific Islander
Haitian Multi-ethnic Other
undisclosed
Multiracial Other
None identified
What has caused person to seek services now?:






Collateral Contacts
Name
Phone number/Location
Need/want this
support: (CHECK)
Insurance Provider:


PCP:


Clinician:


Psychiatrist:


DCF:


School:


Guardian:


Family/Sig Other:


Other:

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Abusers name:
__________________________________
DOB:
__________________________________
Address:
__________________________________
__________________________________
Do you have a TRO/RO?: Yes No
If no, do you want one?: Yes No
Will abuser look for you?: Yes No

Have the police ever been called during
this relationship?: Yes No
If yes, describe:

Violence History
Abusers relation to client: ____________
__________________________________
Does client feel the abuser is dangerous?:
Yes No Describe: ________________
__________________________________
__________________________________

Brief description of offender:

Does abuser have any weapons?

Yes No If yes, what type?: Gun
Knife Other: _________________
__________________________________


Has the Perpetrator ever been arrested? Yes No Describe: ___________________
_________________________________________________________________________
Has the Perpetrator ever been incarcerated? Yes No Describe: ________________
_________________________________________________________________________
Has the Individual ever been arrested? Yes No Describe: ____________________
_________________________________________________________________________
Has the Individual ever been incarcerated? Yes No Describe: __________________
_________________________________________________________________________
Sometimes men will hurt or try to hurt
Describe the most recent incident:
women either physically or by what they
do or say. Has this ever happened to

you? Yes No

How often?: Always Usually
Sometimes Once or twice Never

Describe:

__________________________________
__________________________________ Did the client require medical treatment?: Yes No Unknown
__________________________________ Was a weapon threatened or used? Yes No If yes, what kind?: ________________
Does your partner abuse the kids? _________________________________________________________________________

Yes No Unknown
Did the abuser use drugs or alcohol before the abuse happened? Yes No
If yes, describe: ____________________ Unknown If yes, describe: __________________________________________________
__________________________________ _________________________________________________________________________
__________________________________ ________________________________________________________________________
DCF involved? Yes No If yes,
Did the abuser make jealous comments before the abuse incident? Yes No
describe:
Unknown If yes, describe: _________________________________________________
__________________________________ _________________________________________________________________________
__________________________________ ________________________________________________________________________
__________________________________ Were the police called during the incident? Yes No If yes, describe: ____________
__________________________________ _________________________________________________________________________
__________________________________ _________________________________________________________________________
__________________________________ Were the police ever called? Yes No If Yes, describe: ________________________
Other court involvement with the
_________________________________________________________________________
children? Yes No If yes, describe:
_________________________________________________________________________
__________________________________ _________________________________________________________________________
__________________________________ _________________________________________________________________________
__________________________________ _________________________________________________________________________
Did the children witness the most recent Is the client aware of options available to her thorough the Justice system?:
incident described? Always Usually
Y es

No Unknown
Sometimes Once or twice Never


Through the housing system?:
Did the children witness any episodes of Yes No Unknown

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fighting? Always Usually
Sometimes Once or twice Never

Relational Information
Clients relationship to abuser(s)
Has husband/boyfriend been married
Spouse/Partner Ex-Spouse/Partner before?: Yes No
st
nd
rd
dating/boyfriend Ex-boyfriend
1 2 3 other: ______________
dating/girlfriend Ex-girlfriend If yes, when: ________________________
friend/acquaintance child Where:

____________________________
Roommate Other Relative
To whom?:__________________________
Parent/Step-parent/guardian
___________________________________
Unknown/Undisclosed
What about your relationship makes you
Other:
happy?: Describe:
__________________________________
If married,
st
nd
rd
1 2 3 other: ____________
If Yes, (Explore: when, where, how old, how old

Was marriage arranged? YesNo N/A

If yes, by whom?: ____________________
____________________________________
____________________________________
When?: ____________________________
Did you feel pressured? Yes No N/A
What do you NOT like about your
relationship?: Describe:

were you):

__________________________________
__________________________________
__________________________________
__________________________________
What made both of you decide to get
married?:
__________________________________
__________________________________
What is your idea of a good relationship? (Explore: How does a female act in a good relationship?
How does a man act? How do they work out their problems or disagreements):

Who came to the US first? client

spouse together

Did your spouse already have US
citizenship? Yes No


Think about your relationship before you came to the US, (the things you went through When and where did you meet him/her?
(Explore: how old was client, what country, arranged):
in the past and why you came to the US); Do you think they made your relationship

difficult? Yes No

If yes, in what way:







How often does the abuser:
How often do you:
Gamble Use alcohol Use Drugs
Gamble Use alcohol Use drugs
Describe how this makes your relationship unhappy or stressful: Describe how this makes your relationship unhappy or stressful:




Physical/Mental Health
Medication(s) list:
Individual is/has been suicidal: Yes No
Individual is/has been violent: Yes No
N/A Unknown
Describe:
Describe:


Individual has been admitted into a hospital
Individual is/has been admitted to a substance
for mental health reasons: Yes No
abuse treatment center: Yes No

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Describe:

Describe:

Assessments/Plans
CTS-2 Short Form Completed PMWI-F Short Form Completed
Safety Plan Completed
Release of Information for Collateral Contacts
Completed declined Why/for whom: _____________
________________________________________________
Summary of Intake Screening
Preliminary Risk Assessment:
Summary of Protective Factors: _______________________________________________
No Risk Low Risk __________________________________________________________________________

Mild to Moderate Risk Severe Risk
__________________________________________________________________________
__________________________________________________________________________

Rational for Risk Assessment:






Determination
Individual accepted into program Date: ____________________

ATASK Community Based Services
ATASK Emergency Shelter
ATASK Transitional Housing Program
Individual accepted into program, but declines.
Reason: _______________________________________________________________________________________________________
Individual NOT accepted into program
Reason: _______________________________________________________________________________________________________
Referral(s) made: To: _________________________ Reason: __________________________________________________________
Follow-up/Outcome: ____________________________________________________________________________
To: _________________________ Reason: __________________________________________________________
Follow-up/Outcome: ____________________________________________________________________________

Safety Plan
Indicate Safety Plan:










Staff Name:
Staff Signature
Date:
Supervisor Name:
Supervisor Signature:
Date:
Length of Intake: 1 hour or less 1-2 hours 2-4 hours over 4
History of Abuse Completed
IPV Strategies Index Completed

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