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Domestic Violence
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Children Exposed to Violence
Teen Dating Violence
Programs
Pregnant Moms’ Empowerment Program
Elder Abuse
What is Elder Abuse?
Report Abuse
About CREA
Who We Are
Mission and Vision
Staff
Leadership and Community Partners
Resources
Are You at Risk?
Client Forms
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Safe at Home
Informational Videos
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Client Forms
Please complete this intake form before your appointment. You may complete it online here or you may download a blank PDF to print out and bring with you to your appointment.
Download PDF
Family Safety Center of Memphis and Shelby County
Intake Form
Step
1
of
6
16%
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
WHAT ARE YOUR NEEDS/GOALS? (I WOULD LIKE TO TALK TO SOMEONE ABOUT)
Order of Protection
Counseling
Emergency Housing
Child Therapy
Court Advocate
Legal Assistance - OP
Job/Educational Training
Pregnant Mom's Empowerment Program
Criminal Injuries Compensation
Sexual Assault
Other
Other:
HAVE YOU BEEN ARRESTED AND HAVE PENDING CHARGES FOR DOMESTIC ABUSE?
YES
NO
ARE YOU HERE FOR AN ORDER OF PROTECTION? (IF YES PLEASE SEE BELOW)
YES
NO
Do you have a COMPLETE ADDRESS for the abuser whom you are filing on? (If so, Please fill out address below)
YES
NO (Please speak with the receptionist, we must have a valid address for law enforcement to serve the abuser with court papers.)
Please provide full address of the abuser you are filing on:
Street Address
City
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
State
ZIP Code
DO YOU HAVE A SAFE PLACE TO STAY?
YES
NO
DID THE POLICE HAVE YOU SPEAK WITH AN ADVOCATE FROM THE FAMILY SAFETY CENTER ON THE PHONE WHILE TAKING YOUR REPORT?
YES
NO
DO YOU HAVE AN APPOINTMENT TO SPEAK WITH A DV DETECTIVE/INVESTIGATOR TODAY?
YES
NO
Family Safety Center Intake Form
Today's Date
MM slash DD slash YYYY
FIRST VISIT WITH FAMILY SAFETY CENTER?
YES
NO
Client Information
(Required)
First
Middle
Last
Is this your legal name?
YES
NO
If not, what is your legal name?
Birth Date
(Required)
MM slash DD slash YYYY
Age
(Required)
Please enter a number from
0
to
100
.
Gender?
Male
Female
Transgender
Other
Pronoun
He
She
They/Them
LGBTQ?
YES
NO
Current Address
Street Address
City
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
State
ZIP Code
Safe Phone Number
Safe Email Address
SSN#
Employer:
Employer Address:
Employer Phone Number:
REFFERED BY:
Law Enforcement
District Attorney Office
Social Service
TV/Radio
Family/Friends
Internet
Church/Minister
Print Ad
Other
Other:
Demographic Information
Education Level
8th grade or less
Some High School
High School Grad/GED
Some College
Tech School/Vocational
Bachelor's Degree
Advanced Degree
Relationship to Abuser
Spouse
Ex-Spouse
Boyfriend/Girlfriend
Ex-Boyfriend/Ex-Girlfriend
Child's Parent
Other
Income Level
$0 - $20,000
$20,001 - $35,000
$35,001 - $50,000
$50,001 or more
Military Affiliation
None
Air Force
Army
Coast Guard
Marines
Navy
Other
Military Status
Active Duty
Reserves
Retired
Other
Current Marital Status:
Single
Married
Divorced
Separated
Widowed
Ethnicity:
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
Native American
White/Caucasian
Decline to Answer
Other
Do you have a Disability?
YES
NO
Decline to answer
In order to assess safety, we would like to know if you could be pregnant:
YES
NO
UNCERTAIN
Decline to answer
In Case of Emergency
Name of local friend or relative (not living at same address):
Relationship to Client
Home Phone #
Work Phone #
Please list all Minor Children:
Name:
First
Last
Date of Birth:
MM slash DD slash YYYY
Gender:
Male
Female
Transgender
Other
Race:
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
Native American
White/Caucasian
Decline to Answer
Other
Is Abuser the Parent?
YES
NO
Disability?
YES
NO
Living with you?
YES
NO
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender:
Male
Female
Transgender
Other
Race:
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
Native American
White/Caucasian
Decline to Answer
Other
Is Abuser the Parent?
YES
NO
Disability?
YES
NO
Living with you?
YES
NO
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender?
Male
Female
Transgender
Other
Race:
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
Native American
White/Caucasian
Decline to Answer
Other
Is Abuser the Parent?
YES
NO
Disability?
YES
NO
Living with you?
YES
NO
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender?
Male
Female
Transgender
Other
Race:
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
Native American
White/Caucasian
Decline to Answer
Other
Is Abuser the Parent?
YES
NO
Disability?
YES
NO
Living with you?
YES
NO
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender:
Male
Female
Transgender
Other
Race:
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
Native American
White/Caucasian
Decline to Answer
Other
Is Abuser the Parent?
YES
NO
Disability?
YES
NO
Living with you?
YES
NO
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender:
Male
Female
Transgender
Other
Race:
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
Native American
White/Caucasian
Decline to Answer
Other
Other
Is Abuser the Parent?
YES
NO
Disability?
YES
NO
Living with you?
YES
NO
ABUSER INFORMATION
Name
First
Middle
Last
Other Alias/AKA
Has this person been arrested for the current incident?
YES
NO
Is this person currently in jail?
YES
NO
Date of Birth
MM slash DD slash YYYY
Approx. Age
Please enter a number from
0
to
150
.
SSN#
Abuser Phone #
Abuser address:
Street Address
City
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
State
ZIP Code
NOTE: THIS MUST BE A PHYSICAL ADDRESS WHERE THE SHERIFF CAN SERVE THE ABUSER
Second address (if available):
Street Address
City
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
State
ZIP Code
ABUSER EMPLOYMENT INFORMATION
Employer Name
Employer Address
Street Address
Address Line 2
City
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
State
ZIP Code
Employer Phone #
Work Hours:
Abuser Vehicle Information
Make/Model
License Plate #
Color
State
Additional Information on Abuser:
Height
ex. 5'7"
Weight
Hair Color
Eye Color
Gender
MALE
FEMALE
TRANSGENDER
Other
Race
Asian/Pacific Islander
African American/Black
Hispanic/Latino
Multiracial
White/Caucasian
Decline to Answer
Other
Scars or Tattoos?
Do you and the abuser live together?
YES
NO
If you live with the abuser, has he/she/they moved out of the residence?
YES
NO
If you live together, who owns/leases the residence?
Has the abuser been abusive to you in the past?
YES
NO
Have you received medical treatment in the past?
YES
NO
Are there any court cases pending in which you and the abuser are involved?
YES
NO
If Married, has a divorce been filed?
YES
NO
Does the abuser have any alcohol/drug/or mental health issues?
YES
NO
INFORMATION ABOUT YOUR COMPLAINT
Please be detailed about an incident. The incident statement should include what happened during the incident(s) against you, or your children by the abuser. If you have any questions, please ask a Family Safety Center Staff Member.
Date of Incident
MM slash DD slash YYYY
Time of Incident
Hours
:
Minutes
AM
PM
AM/PM
Location of Incident
Did the incident occur inside of Shelby County?
YES
NO
If No, Where?
Did Your Child Witness this incident of domestic violence?
YES
NO
Does your child/children need protection from the abuser?
YES
NO
If yes, please explain why the child/children need protection below:
Please note, this must be based on incidents of harm or threats by the abuser towards the child/children.
POLICE REPORT#
Incident Date:
MM slash DD slash YYYY
What Happened?
Petitioner's (Your) Signature:
First
Last
Today's Date:
MM slash DD slash YYYY
Were you injured?
YES
NO
If so, did you receive medical treatment?
YES
NO
Where did you receive medical treatment?
Were the Police Called?
YES
NO
Was a report Taken?
YES
NO
UNSURE
Was anyone arrested?
YES
NO
If so, who?
What was the charge?
Were any weapons used?
YES
NO
If so, what?
Have you received harassing phone calls or text messages?
YES
NO
If so, how many?
Did this person threaten to hurt or kill you during these calls or text?
YES
NO
How many threats via Phone/Text?
When did it start?
MM slash DD slash YYYY
What is the date of the most recent?
MM slash DD slash YYYY
Did you report to police?
YES
NO
Hidden
Adverse Childhood Assessment (ACE)
The Following questions are about while you were growing up in your FIRST 18 YEARS of life.
Hidden
Did a parent or other adult in the household often ..... Swear at you, insult you, put you down, or humiliate you or act in a way that made you afraid you could be hurt?
YES
NO
Hidden
Did a parent or other adult in the household often .... Push, grab, slap, or throw something at you? Or EVER hit you so hard that you had marks or were injured?
YES
NO
Hidden
Did an adult or person at least 5 years older than you EVER .... touch or fondle you or have you touch their body in a sexual way? Or Try to or actually have oral, anal, vaginal sex with you?
YES
NO
Hidden
Did you OFTEN feel that ... No one in your family loved you or thought you were important or special? OR Your family didn't look out for each other, feel close to each other, or support each other?
YES
NO
Hidden
Did you OFTEN feel that ..... You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you OR Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
YES
NO
Hidden
Were your parents ever divorced or separated?
YES
NO
Hidden
Was your mother, or step-mother OFTEN pushed, grabbed, slapped or had something thrown at them? Or often kicked, bitten, hit with a fist, or hit with something hard? OR EVER repeatedly hit over a few minutes time or threatened with a gun or knife?
YES
NO
Hidden
Did you live with anyone who was a problem drinker or alcoholic or used street drugs?
YES
NO
Hidden
Was a household member depressed or mentally ill or did a household member attempt suicide?
YES
NO
Hidden
Did a household member go to prison?
YES
NO
Hidden
PLEASE READ PRIOR TO ANSWERING:
No matter how well a couple gets along, there are times when they disagree, get annoyed with one another, want different things from each other, or just have spats/fights because they are in a bad mood, tired, or are upset for some reason. Couples also have many different ways of trying to settle their differences. This is a list of things that MIGHT happen when you have differences with your Partner. Some of these questions may be about you, others about your partner. Please fill in the appropriate dot that best describes how many times these things have happened in -THE PAST 3 MONTHS-
Hidden
My Partner insulted me or swore at me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner threw something at me that could have hurt:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner twisted my arm or hair:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner had a sprain, bruise, or small cut because of a fight with me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner made me have sex without a condom:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner pushed or shoved me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner used force to make me have oral or anal sex:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner used a gun or knife on me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner passed out from being hit on the head by me in a fight:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner called me fat or ugly:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner punched or hit me with something that could hurt:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner destroyed something that belonged to me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner went to a doctor because of a fight with me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner choked me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner shouted or yelled at me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner slammed me against a wall:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner needed to see a doctor because of a fight with me, but didn't:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner beat me up:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
My Partner grabbed me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner used force to make me have sex:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner stomped out of the house/room/yard during a disagreement:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner insisted I have sex when I didn't want to (but did not use physical force):
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner slapped me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner had a broken bone from a fight with me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner used threats to make me have oral or anal sex:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner burned or scalded me on purpose:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner insisted I have oral or anal sex (But didn't use physical force):
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My partner accused me of being a lousy lover:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My Partner did something to spite me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My partner threatened to hit or throw something at me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My partner still felt physical pain the next day because of a fight we had:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My partner kicked me:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
My partner used threats to make me have sex:
Once
Twice
3-4 Times
6-10 Times
11-20 Times
More than 20 Times
NOT IN PAST 3 MONTHS
NEVER
Hidden
HERTH HOPE INDEX - BEFORE NAVIGATOR MEETING
Listed below are a number of statements. Read each statement and choose a box that describes how much you agree with that statement right now.
Hidden
I have a positive outlook toward life.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I have short and/or long range goals.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I feel all alone.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I can see possibilities in the midst of difficulties.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I have a faith that gives me comfort.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I feel scared about my future.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I can recall happy/joyful times.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I have deep inner strength.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I am able to give and receive caring/love.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I have a sense of direction.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I believe that each day has potential.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
I feel my life has value and worth.
STRONGLY AGREE
AGREE
DISAGREE
STRONGLY DISAGREE
Hidden
CLIENT SURVEY
Your feedback is essential to improving our processes and the level of service you receive. Please fill out this survey, along with your paperwork to the submit upon completion.
Hidden
Would you like to see the Family Safety Center have extended office hours? If so, please indicate below the hours you think would be most helpful (CHOOSE ONE)
MON-FR1 8AM-7PM
SAT. 8AM-2PM
SAT 8AM-4:30PM
Hidden
Please check which services you would like to see available during extended hours:
Law Enforcement
Shelter Housing
Order of Protection
Childcare Service
Other
Hidden
"Other" Please Specify
Hidden
Would you take advantage of services of the Family Safety Center located at satellite offices throughout Memphis?
YES
NO
Hidden
Which would you more likely use?
Option Style Shelter (individual hotels or apartments)
Shared Living Quarters
Hidden
Number
