Culturally Sensitive Domestic Violence Intake Form
Personal Information
Full Name:
Pronouns (if any):
Date of Birth:
Preferred Contact Method:
Cultural Identity
Cultural Background/Ethnicity:
Primary Language Spoken:
Religious/Spiritual Beliefs:
Do you require an interpreter?
Yes
No
Situation
Relationship to Alleged Abuser:
How long have you experienced this situation?
Type(s) of Abuse Experienced (select all that apply):
Physical
Emotional
Sexual
Financial
Other
Briefly describe your situation:
Cultural Considerations
Are there any cultural practices or customs we should be aware of to better support you?
Is there anything else you would like to share about your preferences for support or safety?
Safety & Support
Is it safe for us to contact you? If yes, indicate preferred days/times:
Emergency Contact (optional):
Support Network (family, friends, community):