Immigrant & Refugee Domestic Violence Client Intake Sheet

Personal Information

Full Name Date of Birth Phone Number Email Address Address Preferred Language Country of Origin Immigration Status

Household Information

Number of Adults in Household Number of Children in Household Relationship to Abuser

Incident Details

Date of Most Recent Incident Describe the Nature of Abuse Is Abuser Living With You? Yes No

Legal/Support Information

Do you have a restraining/protection order? Yes No Are you working with an attorney? Yes No Do you need an interpreter? Yes No

Additional Notes/Concerns