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Home
Programs
Homeownership
Homebuyers
Foreclosure Prevention
Reverse Mortgage Counseling
Lending
Financial Education & Coaching
Financial Coaching
Student Debt Solutions
Bankruptcy Counseling
Pre-file Bankruptcy
Post-file Bankruptcy
Financial Peace
Debt Management
Professional Fiduciary Services
Conservator
Conservator Financial Education & Counseling
Trustee
Personal Representative / Executor
VA Fiduciary
Power of Attorney Agent
Housing Stability
Representative Payee
Eviction Prevention
Family Violence Intervention
Anger Management
Batterers Intervention
Domestic Violence Victims Program
Workshops
FREE Intro to Homeownership Workshop
FREE Credit Improvement & Making Ends Meet Workshop
Table Talk Tuesdays
Ehome America Homebuyer Course
Bankruptcy Counseling
Reverse Mortgage
Men’s Batterers Intervention
Men’s Anger Management
Women’s Anger Management
Women’s Batterers Intervention
Virtual Classroom
Invite us to your location
Get Involved
Careers
Special Events
Volunteer
Donate Now
Spring Fundraiser Event
Housing & Financial Stability Donations
Family Violence Intervention Donations
About
Annual Reports
News
Our History
Our Impact
Our Staff
Our Board
Privacy Policy
Contact
843.628.3000
Home
Intake – Family Violence Intervention Program
Intake – Family Violence Intervention Program
Family Violence Intervention Program Intake Packet
General Information
Referral Source
*
--Select--
DSS
Court
Self
Other
Please indicate who you were referred by
Type of Service Requested
*
--Select--
Batterer's Intervention
Anger Management
Empowerment Classes
Please select the service(s) you have been recommended for
Date
*
MM slash DD slash YYYY
Name
*
First
Last
Phone
*
Email
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Hidden
County of Residence
--Select--
Charleston
Dorchester
Berkeley
Other
Sexual Orientation
--Select--
Heterosexual
Gay
Bisexual
Lesbian
Asexual
Pansexual
Other
Gender
--Select--
Male
Female
Do not wish to identify
Agender (nonconforming)
Transgender
Transgender (Male)
Transgender (Female)
Other
Race
--Select--
African American
White
Asian
Hispanic/Latino
Bi-Racial
American Indian
Pacific Islander
Multi-Racial
Other
Do not wish to identify
Age Range
--Select--
0-17
18-24
25-29
30-35
36-40
41-45
46-50
51-55
56-59
60-65
66-70
70+
Police Report Filed
Yes
No
Are you Employed?
Yes
No
Are you a Student?
Yes
No
Are you Disabled?
Yes
No
What is your Monthly Income?
$0-$1,000
$1,001- $1,999
Household Income
$2,000-$2,999
$3,000-$3,999
>$4,000
History
Please select all that apply
History
Select all that applies
Child Abuse (Physical)
Child Abuse (Sexual)
Child Abuse (Incest)
Child Pornography
Child Domestic Violence Witness
Kidnapping (non-custodial)
Kidnapping (custodial)
Teen Dating Victimization
Domestic Violence
Protective Order
Elder Abuse
Stalking/harassment
DUI/DWI Crashes
Other Vehicular ( e.g. hit and run)
Terrorism (domestic/international)
Other Victim of Crime
Emergency Medical Services
Law Enforcement Intervention
Open/Past Mental Health History
Open/Past Dept. of Juvenile Justice
Open/Current Criminal History
Arson
Adult Sexual Assault
Adult Physical Assault
Robbery/Burglary
Bullying
Hate Crime
Human Trafficking: Labor
Human Trafficking: Sex
Identity theft/financial crime
Alcohol Abuse
Drug Abuse
Survivor of Homicide Victim
Child Abuse (Physical) Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Child Abuse (Sexual)- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Child Abuse (Incest)- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Child Pornography- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Kidnapping (non-custodial)- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Kidnapping (custodial)- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Domestic Violence- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Protective Order- Petitioner/ Respondent
*
--Select--
Petitioner
Respondent
Elder Abuse- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Stalking/harassment- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Adult Sexual Assault- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Adult Physical Assault- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Robbery/Burglary- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Bullying- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Human Trafficking: Labor- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Human Trafficking: Sex- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Identity theft/fraud/financial crime-Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Special Classification of Individuals
Please select all that apply
Deaf/hard of hearing
Homeless
Immigrants/refugees/asylum seekers
Limited English proficiency
Disabled: physical/mental/intellectual
Veterans
N/a
Outcome Measurements Pre-Group Survey
Please take a few minutes to complete this brief survey. This is not a test- be honest! Your answers will greatly increase our ability to help you and others! THE INFORMATION THAT YOU PROVIDE TO US IS STRICTLY CONFIDENTIAL!
Name:
Age:
Race:
Gender:
Are you currently employed?
Full-Time
Part-Time
Unemployed
What is your current monthly income?
Do you have a High School Diploma or GED?
Yes
No
List as many of the early warning signs of violent behavior that you can think of:
Do you know what a personal safety plan is?
Yes
No
If so, do you have a personal safety plan?
Yes
No
How often have you or your past or current partner done any of the following?
Yelled at you
Daily
Weekly
Monthly
Once
Never/NA
Threatened to hit you
Daily
Weekly
Monthly
Once
Never/NA
Threatened to kill you
Daily
Weekly
Monthly
Once
Never/NA
Threatened to hurt the children
Daily
Weekly
Monthly
Once
Never/NA
Grabbed or pushed you
Daily
Weekly
Monthly
Once
Never/NA
Hit or slapped you
Daily
Weekly
Monthly
Once
Never/NA
If any of these event's happened to you. What did you do?
Name 3 things that you hope to accomplish through counseling.
PCL-5
Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem IN THE PAST MONTH.
1. Repeated, disturbing and unwanted memories of the stressful expperience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back in there reliving it?)
Not at all
A little bit
Moderately
Quite a bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
6. Avoiding memories, thoughts or feelings related to the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
8. Trouble remembering important parts of the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
10. Blaming yourself or someone else for the stressful experience or what happened after it?
Not at all
A little bit
Moderately
Quite a bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt or shame?
Not at all
A little bit
Moderately
Quite a bit
Extremely
12. Loss of interest in activities that you used to enjoy?
Not at all
A little bit
Moderately
Quite a bit
Extremely
13. Feeling distant or cut off from other people?
Not at all
A little bit
Moderately
Quite a bit
Extremely
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
15. Irritable behavior, angry outbursts, or acting aggressively?
Not at all
A little bit
Moderately
Quite a bit
Extremely
16. Taking too many risks or doing things that could cause you harm?
Not at all
A little bit
Moderately
Quite a bit
Extremely
17. Being "super-alert" or watchful or on guard?
Not at all
A little bit
Moderately
Quite a bit
Extremely
18. Feeling jumpy or easily startled?
Not at all
A little bit
Moderately
Quite a bit
Extremely
19. Having difficulty concentrating?
Not at all
A little bit
Moderately
Quite a bit
Extremely
20. Trouble falling or staying asleep?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Self Esteem Survey
Directions: Please circle the number for each question that best describes your agreement with each statment.
1. I feel that I'm a person of worth at least on an equal par with others.
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
2. I feel that I have a number of good qualities
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
3. All in all, I am inclined to feel that I'm a failure.
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Stongly Disagree
4. I am able to do things as well as most other people
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
5. I feel I do not have much to be proud of.
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
6. I take a positive attitude towards myself
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
7. On a whole, I am satisfied with myself
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
8. I wish I could have more respect for myself
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
9. I certainly feel useless at times
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
10. At times I think that I am no good at all
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
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