Domestic Violence Case Intake Assessment
Client Information
Full Name
Date of Birth
Contact Number
Address
Preferred Contact Method
Phone
Email
Other
Incident Details
Date of Incident
Location of Incident
Description of Incident
Relationship to Alleged Abuser
Previous Incidents
Safety Assessment
Is the client in immediate danger?
Yes
No
Unsure
Are children or dependents involved?
Yes
No
Does anyone require medical attention?
Yes
No
Support Needs
Does the client need legal support?
Yes
No
Is emergency shelter needed?
Yes
No
Would the client like counseling services?
Yes
No
Other Needs or Requests