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Intake – Family Violence Intervention Program

Family Violence Intervention Program Intake Packet

General Information
Referral Source*
Please indicate who you were referred by
Type of Service Requested*
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 ZIP Code
Hidden
County of Residence
Sexual Orientation
Gender
Race
Age Range
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*
Child Abuse (Sexual)- Survivor/Perpetrator*
Child Abuse (Incest)- Survivor/ Perpetrator*
Child Pornography- Survivor/ Perpetrator*
Kidnapping (non-custodial)- Survivor/ Perpetrator*
Kidnapping (custodial)- Survivor/ Perpetrator*
Domestic Violence- Survivor/Perpetrator*
Protective Order- Petitioner/ Respondent*
Elder Abuse- Survivor/ Perpetrator*
Stalking/harassment- Survivor/ Perpetrator*
Adult Sexual Assault- Survivor/Perpetrator*
Adult Physical Assault- Survivor/ Perpetrator*
Robbery/Burglary- Survivor/ Perpetrator*
Bullying- Survivor/ Perpetrator*
Human Trafficking: Labor- Survivor/ Perpetrator*
Human Trafficking: Sex- Survivor/Perpetrator*
Identity theft/fraud/financial crime-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.
2. I feel that I have a number of good qualities
3. All in all, I am inclined to feel that I'm a failure.
4. I am able to do things as well as most other people
5. I feel I do not have much to be proud of.
6. I take a positive attitude towards myself
7. On a whole, I am satisfied with myself
8. I wish I could have more respect for myself
9. I certainly feel useless at times
10. At times I think that I am no good at all

Family Violence Intervention Program Intake Packet

General Information

History

Outcome Measurements Pre-Group Survey

How often have you or your past or current partner done any of the following?

PCL-5

Self Esteem Survey