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Domestic violence victim intake form

Domestic violence victim intake forms are used by police and domestic violence agencies to gather information about an incident of domestic violence. The form is used to document the victim's account of what happened, as well as any injuries sustained. The form is also used to collect information about the perpetrator, including their name, address, and any previous history of domestic violence.

Time to complete

3 minutes

Eligibility

Anyone who is a victim of domestic violence or has witnessed domestic violence can fill out a domestic violence victim intake form.

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Questions for Domestic violence victim intake form

1.

What is your name?

The answer should be a text input.
2.

What is your current address?

The answer should be a text input.
3.

What is your phone number?

The answer should be a phone number.
4.

What is your email address?

The answer should be an email input.
5.

What is your date of birth?

The answer should be a date input.
6.

What is your current relationship status?

The answer should be a single choice:
  1. Single
  2. Married
  3. Seperated
  4. Committed
7.

What is your employment status?

The answer should be a single choice:
  1. Employed
  2. Unemployed
8.

Do you have any children? If so, how many and what are their ages?

The answer should be a text input.
9.

What are your hobbies and interests?

The answer should be a text input.
10.

Tell me about your family.

The answer should be a text input.
11.

Tell me about your relationship with your partner.

The answer should be a text input.
12.

When did the abuse start?

The answer should be a text input.
13.

Describe the abuse

The answer should be a text input.
14.

How often does the abuse occur?

The answer should be a text input.
15.

What is the nature of the abuse?

The answer should be a text input.
16.

Is there any history of domestic violence in your family?

The answer should be a text input.

Similar Ideas

  • Domestic Violence Intake Form
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  • Domestic Violence Financial Disclosure
  • Domestic Violence Legal Rights and Responsibilities
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  • Domestic Violence Personal Safety Plan
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Here are some FAQs and additional information
on Domestic violence victim intake form

What is the purpose of the Domestic Violence Victim Intake Form?

The form is used to gather information from victims of domestic violence in order to provide them with appropriate services and support.

Who is required to complete the form?

Any victim of domestic violence who is seeking services from a domestic violence program or organization.

How long does the form take to complete?

The form should take no more than 10 minutes to complete.

What information is required on the form?

The form requires basic information about the victim, such as name, contact information, and relationship to the abuser. Additionally, the form asks questions about the nature and severity of the domestic violence, as well as the victim's current situation and needs.

Is the information on the form confidential?

Yes, the information on the form is confidential and will only be shared with staff members of the domestic violence program or organization

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Domestic violence victim intake form
Domestic violence victim intake forms are used by police and domestic violence agencies to gather information about an incident of domestic violence. The form is used to document the victim's account of what happened, as well as any injuries sustained. The form is also used to collect information about the perpetrator, including their name, address, and any previous history of domestic violence.

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