843.628.3000
Home
Programs
Homeownership
Homebuyers
Reverse Mortgage Counseling
Financial Education & Coaching
Financial Coaching
Student Loan Counseling
Bankruptcy Counseling
Pre-file Bankruptcy
Post-file Bankruptcy
Debt Management
Professional Fiduciary Services
Conservator
Conservator Financial Education & Counseling
Trustee
Personal Representative / Executor
VA Fiduciary
Power of Attorney Agent
Representative Payee
Housing Stability
Eviction Prevention
Foreclosure 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
Ehome America Homebuyer Course
Bankruptcy Counseling
Men’s Batterers Intervention
Men’s Anger Management
Women’s Anger Management
Women’s Batterers Intervention
Virtual Classroom
Get Involved
Careers
Special Events
Volunteer
Donate Now
Donate to Origin SC
Survivors of Crime Donations
About
Annual Reports
Our History
Our Impact
Our Staff
Our Board
Our Blog
Privacy Policy
Contact
Home
Programs
Homeownership
Homebuyers
Reverse Mortgage Counseling
Financial Education & Coaching
Financial Coaching
Student Loan Counseling
Bankruptcy Counseling
Pre-file Bankruptcy
Post-file Bankruptcy
Debt Management
Professional Fiduciary Services
Conservator
Conservator Financial Education & Counseling
Trustee
Personal Representative / Executor
VA Fiduciary
Power of Attorney Agent
Representative Payee
Housing Stability
Eviction Prevention
Foreclosure 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
Ehome America Homebuyer Course
Bankruptcy Counseling
Men’s Batterers Intervention
Men’s Anger Management
Women’s Anger Management
Women’s Batterers Intervention
Virtual Classroom
Get Involved
Careers
Special Events
Volunteer
Donate Now
Donate to Origin SC
Survivors of Crime Donations
About
Annual Reports
Our History
Our Impact
Our Staff
Our Board
Our Blog
Privacy Policy
Contact
843.628.3000
Home
Intake – Family Violence Intervention Program
Intake – Family Violence Intervention Program
Family Violence Intervention Program Intake Packet
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
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
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
Prefer not to identify
Gender
*
--Select--
Male
Female
Agender (nonconforming)
Transgender
Transgender (Male)
Transgender (Female)
Other
Prefer not to identify
Race
*
--Select--
African American
White
Asian
Hispanic/Latino
Bi-Racial
American Indian
Pacific Islander
Multi-Racial
Other
Prefer not to identify
Family Size
*
1-4
5-10
>10
Prefer not 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+
Prefer not to identify
Police Report Filed
*
Yes
No
Prefer not to identify
Are you Employed?
*
Yes
No
Prefer not to identify
Are you a Student?
*
Yes
No
Prefer not to identify
Are you Disabled?
*
Yes
No
Prefer not to identify
What is your Monthly Income?
*
$0-$1,000
$1,001- $1,999
Prefer not to identify
Household Income
*
$2,000-$2,999
$3,000-$3,999
>$4,000
Prefer not to identify
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
Prefer not to identify
Child Abuse (Sexual)- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Child Abuse (Incest)- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Child Pornography- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Kidnapping (non-custodial)- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Kidnapping (custodial)- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Domestic Violence- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Protective Order- Petitioner/ Respondent
*
--Select--
Petitioner
Respondent
Prefer not to identify
Elder Abuse- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Stalking/harassment- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Adult Sexual Assault- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Adult Physical Assault- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Robbery/Burglary- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Bullying- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Human Trafficking: Labor- Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Human Trafficking: Sex- Survivor/Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
Identity theft/fraud/financial crime-Survivor/ Perpetrator
*
--Select--
Survivor
Perpetrator
Prefer not to identify
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
Hidden
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!
Hidden
Name:
Hidden
Age:
Hidden
Race:
Hidden
Gender:
Hidden
Are you currently employed?
Full-Time
Part-Time
Unemployed
Hidden
What is your current monthly income?
Hidden
Do you have a High School Diploma or GED?
Yes
No
Hidden
List as many of the early warning signs of violent behavior that you can think of:
Hidden
Do you know what a personal safety plan is?
Yes
No
Hidden
If so, do you have a personal safety plan?
Yes
No
Hidden
How often have you or your past or current partner done any of the following?
Hidden
Yelled at you
Daily
Weekly
Monthly
Once
Never/NA
Hidden
Threatened to hit you
Daily
Weekly
Monthly
Once
Never/NA
Hidden
Threatened to kill you
Daily
Weekly
Monthly
Once
Never/NA
Hidden
Threatened to hurt the children
Daily
Weekly
Monthly
Once
Never/NA
Hidden
Grabbed or pushed you
Daily
Weekly
Monthly
Once
Never/NA
Hidden
Hit or slapped you
Daily
Weekly
Monthly
Once
Never/NA
Hidden
If any of these event's happened to you. What did you do?
Hidden
Name 3 things that you hope to accomplish through counseling.
Hidden
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.
Hidden
1. Repeated, disturbing and unwanted memories of the stressful expperience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
2. Repeated, disturbing dreams of the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
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
Hidden
4. Feeling very upset when something reminded you of the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
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
Hidden
6. Avoiding memories, thoughts or feelings related to the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
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
Hidden
8. Trouble remembering important parts of the stressful experience?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
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
Hidden
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
Hidden
11. Having strong negative feelings such as fear, horror, anger, guilt or shame?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
12. Loss of interest in activities that you used to enjoy?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
13. Feeling distant or cut off from other people?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
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
Hidden
15. Irritable behavior, angry outbursts, or acting aggressively?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
16. Taking too many risks or doing things that could cause you harm?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
17. Being "super-alert" or watchful or on guard?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
18. Feeling jumpy or easily startled?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
19. Having difficulty concentrating?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
20. Trouble falling or staying asleep?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Hidden
Self Esteem Survey
Directions: Please circle the number for each question that best describes your agreement with each statment.
Hidden
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
Hidden
2. I feel that I have a number of good qualities
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
3. All in all, I am inclined to feel that I'm a failure.
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Stongly Disagree
Hidden
4. I am able to do things as well as most other people
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
5. I feel I do not have much to be proud of.
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
6. I take a positive attitude towards myself
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
7. On a whole, I am satisfied with myself
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
8. I wish I could have more respect for myself
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
9. I certainly feel useless at times
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
10. At times I think that I am no good at all
--Select--
Strongly Agree
Agree Somewhat
Disagree Somewhat
Strongly Disagree
Hidden
Untitled
First Choice
Second Choice
Third Choice
Questions? Feedback?
powered by
Olark live chat software