Client Forms - Family Safety Center

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.

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Family Safety Center of Memphis and Shelby County
Intake Form

Step 1 of 7

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
Sexual Assault
Counseling
Child Therapy
Child/Safe Exchange
HIV Testing
Emergency Housing
Child Support App.
LGBTQ Resources
Pregnant Moms' Empowerment Program
Utility Assistance**
Rental Assistance**
Immigration Services
Court Advocate
Legal Assistance -OP**
Job/Educational Training
Victim Compensation
Camp Hope
Spiritual Support
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 State / Province / Region ZIP / Postal Code Country

DO YOU NEED TO SPEAK WITH POLICE TODAY?

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 A SAFE PLACE TO STAY?

YES

NO

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?

LGBTQ?

YES

NO
Birth Date(Required)
MM slash DD slash YYYY

AGE(Required)
Please enter a number from 0 to 100.
SEX?

Male

Female

Transgender
Current Address
Street Address City State / Province / Region ZIP / Postal Code Country

Safe Phone Number
Safe Email Address

Drivers License #

SSN#
Employer:

Employer Address:

Employer Phone Number:
REFFERED BY:
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
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
Relationship to Abuser

Spouse/Ex-Spouse

Boyfriend/Girlfriend

Ex-Boyfriend/Ex-Girlfriend

Child's Parent

Other
If you checked "other" please specify:

Military Status

Active Duty

Reserves

Retired

Other
Current Marital Status

Single

Married

Divorced

Separated

Widowed
Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

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
Please List All Minor Children
First Last
Date of Birth
MM slash DD slash YYYY

Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

White/Caucasian

Decline to Answer

Other
SEX?

Male

Female

Transgender
Is Abuser the Parent?

YES

NO
Disability?

YES

NO
Living with you?

YES

NO
Please List All Minor Children
First Last
Date of Birth
MM slash DD slash YYYY

Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

White/Caucasian

Decline to Answer

Other
SEX?

Male

Female

Transgender
Is Abuser the Parent?

YES

NO
Disability?

YES

NO
Living with you?

YES

NO
Please List All Minor Children
First Last
Date of Birth
MM slash DD slash YYYY

Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

White/Caucasian

Decline to Answer

Other
SEX?

Male

Female

Transgender
Is Abuser the Parent?

YES

NO
Disability?

YES

NO
Living with you?

YES

NO
Please List All Minor Children
First Last
Date of Birth
MM slash DD slash YYYY

Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

White/Caucasian

Decline to Answer

Other
SEX?

Male

Female

Transgender
Is Abuser the Parent?

YES

NO
Disability?

YES

NO
Living with you?

YES

NO
Please List All Minor Children
First Last
Date of Birth
MM slash DD slash YYYY

Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

White/Caucasian

Decline to Answer

Other
SEX?

Male

Female

Transgender
Is Abuser the Parent?

YES

NO
Disability?

YES

NO
Living with you?

YES

NO
Please List All Minor Children
First Last
Date of Birth
MM slash DD slash YYYY

Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

White/Caucasian

Decline to Answer

Other
SEX?

Male

Female

Transgender
Is Abuser the Parent?

YES

NO
Disability?

YES

NO
Living with you?

YES

NO
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: (This must be based on incidents of harm or threats by the abuser towards the child/children)

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 #
Employer Name

Employer Address

Complete address where the abuser can be served court documents in person by the Sheriff's Dept. (Address, City and State)
Street Address City State / Province / Region ZIP / Postal Code Country

Note: This must be a good address, so the Sheriff can serve the abuser
Second address (if available)
Street Address City State / Province / Region ZIP / Postal Code Country

Abuser Vehicle Information
Make/Model

License Plate #

Color

State

Additional Information on Abuser:
Height

ex. 5'7"
Weight
Hair Color

Eye Color

Ethnicity:

Asian/Pacific Islander

African American/Black

Hispanic/Latino

Multi-Racial

White/Caucasian

Decline to Answer

Other
Sex?

MALE

FEMALE

TRANSGENDER
Scars or Tattoos?
Do you and the abuser live together?

YES

NO
If you live with the abuser, have they moved out of the residence?

YES

NO
Would you like the abuser to leave your shared 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?

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
In Case of Emergency
Name of local friend or relative (not living at same address):

Relationship to Client

Home Phone #
Work Phone #

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
MM slash DD slash YYYY

Time

Hours

:

Minutes

Location:

Did the incident occur inside of Shelby County?

YES

NO
If No, Where?

POLICE REPORT#

Incident Date:
MM slash DD slash YYYY

What Happened?
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
Do you have a log of these threatening calls/text?

YES

NO
Were they made on your personal cell phone?

YES

NO

Adverse Childhood Assessment (ACE)
The Following questions are about while you were growing up in your FIRST 18 YEARS of life.
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
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
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
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
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
Were your parents ever divorced or separated?

YES

NO
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
Did you live with anyone who was a problem drinker or alcoholic or used street drugs?

YES

NO
Was a household member depressed or mentally ill or did a household member attempt suicide?

YES

NO
Did a household member go to prison?

YES

NO

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-
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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.
I have a positive outlook toward life.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I have short and/or long range goals.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I feel all alone.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I can see possibilities in the midst of difficulties.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I have a faith that gives me comfort.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I feel scared about my future.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I can recall happy/joyful times.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I have deep inner strength.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I am able to give and receive caring/love.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I have a sense of direction.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I believe that each day has potential.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
I feel my life has value and worth.

STRONGLY AGREE

AGREE

DISAGREE

STRONGLY DISAGREE
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.
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
Please check which services you would like to see available during extended hours:
Law Enforcement
Shelter Housing
Order of Protection
Childcare Service
Other
"Other" Please Specify

Would you take advantage of services of the Family Safety Center located at satellite offices throughout Memphis?

YES

NO
Which would you more likely use?

Option Style Shelter (individual hotels or apartments)

Shared Living Quarters

DONATE TODAY!

Family Safety Center of Memphis and Shelby County

Demographic Information

ABUSER INFORMATION

Abuser Vehicle Information

Additional Information on Abuser:

In Case of Emergency

INFORMATION ABOUT YOUR COMPLAINT

Adverse Childhood Assessment (ACE)

PLEASE READ PRIOR TO ANSWERING:

HERTH HOPE INDEX - BEFORE NAVIGATOR MEETING

CLIENT SURVEY

CONTACT INFO

LINKS

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