Intake Questions

All information is confidential.

Name

Birthday

You Need Help Filling Out This Form?

Contact Information (Is there a safe way to contact you?)

Abuser Information (What's their name & gender?)

Children (If services requested are not related to children, this section may be omitted.)

Imediate needs. (Are there immediate concerns that we can help you with?)

This information on this emergency contact form is used to assist you in planning for safety during your stay at the shelter. It is not required for program participation and will not be released without your approval. In the event that you become unconscious, unable to respond to questions or make decisions for yourself, information on this form will be shared on an as needed basis. We will ask you to review this form periodically to ensure accuracy. Because information on this form can be potentially harmful, this form will be destroyed after you leave.

Emergency Contact

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Emergency Information