Client ID First Contact Date Case Close Date:__

ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs

Client ID______Household ID Number______First Contact Date______Case Close Date:______

All questions should be completed within 24 hours of intake. A. CLIENT DEMOGRAPHICS

B. 1. Name:______Date of Birth:______1. Phone intake 2. In-person intake

 Ot her: 2. Gender  Female  Male ______ Not Reported (Client declined) Identity: ______

 Transgender female (male to female): Someone whose sex is or was male but identifies as female

 Transgender male (female to male): Someone whose sex is or was female but identifies as male

 Genderqueer/Gender non-conforming: Someone who does not identify exclusively as male or female, somewhere in between or neither gender identity 3. Age at First Contact: ______

 Non-  Hispanic/La 4. Ethnicity: Hispanic/Non-  Unknown tino Latino  Native 5. Race:  American  Black/Afric Hawaiian/ Check as Indian  Asian  White  Unknown an Other many as or Alaska American Pacific apply Native Islander

6. Sexual  Heterosexu  Homosexua Orientati  Bisexual al/Straight l/Gay/Lesbian on:

 Queer: Refers broadly to lesbians, gay, bisexual people and others who may NOT identify with the terms above but DO identify with this term.

 Other: ______ Not Reported: Client declined or not collected) ______

 Unknown: Note: If client uses the term “Questioning” to describe their sexual orientation, please use the “Other” category above and write in this term.

7. Veteran’  No  Yes  Unknown  Not Reported (e.g., client declined) s Status: 8. Employm  Not  Full Time  Part Time  Unknown ent: Employed

9. Educatio  College  High School  No High  Some College n: Grad or More Grad School Some High  Unknown School

10. Marital  Common  Legally  Divorced  Married  Single  Unknown  Widowed Status: Law Separated

11. Pregnant  Not  No  Unknown  Yes  Not Applicable (male clients only) : Reported

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs

12. Number of Children: ______Name Sex Age

C. PRIMARY PRES ENTI NG  Emotional  Physical DV  Sexual DV Primary Offense Date: ______/______/______ISSUE DV (choo se ONE): 1. Offense  Offender’s  Other  Other  Car  Park  School Location: Home Private Location Public Location  Shared  Victim’s  Victim’s  Street  Other:______Home Home Work  Adult 2. Other  Rape/Sexua  Child sexual survivor incest/  Stalking  Harassment  Child abuse Presenting l Assault child sexual assault Issues: assault (Check as  Child  Home many as  Date rape  Drugged  Hate crime  Physical DV apply) neglect invasion  Emotional  Domestic  Aggravated  Violation of  Sexual DV  Elder abuse DV battery dom. battery OP  Attempted  Other  Homicide  DUI/DWI  Battery  Assault/battery homicide assault  Other offense against  Other  Unknown  Burglary  Robbery person offense offense

 Earned  Worker B. CLIENT Income compensation INCOME $______$______ Pension from former job $______SOURCE(S):  Unemploym Check as ent many as Insurance$______ TANF apply AND ______$______ Child Support $______indicate  Soc Sec MONTHLY Disability amnt. $______ General  SSI assistance $______$______ Alimony/other spouse income $______ Retirement  Veterans income/Soc. disability pay Security$______$______ Other Source______$______

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs  Unknown (-1  Private disability  No financial unknown; -2 not insurance$______ Veteran’s pension $______resources reported)

D. NONCASH BENEFITS/HEALTH INSURANCE: 1. Non Cash Benefits:  Food  TANF Stamps/food Transportati  Other Source benefit card on (Link Card)  Special  Other Supplement TANF funded  No Non Cash benefits al nutrition services (WIC)  Section  TANF 8, public Child Care  Unknown housing, rent services assistance 2. Health Insurance  State  Medicai children’s d health health insurance  Private health insurance insurance (18 and (Children’s older only) Medicaid)  Veteran  Medicar ’s e health administratio  No health insurance insurance n med services  Unknown E. REFERRAL SOURCE: 1. Referred From:  Sexual  Legal  Housing  Circuit  Public Assault  Child Advocacy Center System Program Clerk Health Program  Medical  Private  Hospital Advocacy  Clergy  Media  National DV Hotline Attorney Program  Law  State’s  Educati  Medical  Relative  IL DV Helpline Enforcement Attorney on System  Social  Other  Self Service  DCFS  Friend  Other Local Hotline DV Program Program Other Referrals:______2. Referred To:  State’s  Housing  Other  Legal  Medical Attorney Program DV Program System  Social  Circuit  Law  Private Service  DCFS Clerk Enforcement Attorney Program  Sexual  Public  Educati  Hospital Assault  Clergy Health on System Program

Other Referrals:______

F. No special Unknown Not Reported SPECIAL needs NEEDS (as indicated many as

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs apply):  Is  Has  Requires special diet hearing limited impaired English (primary language:______)  Require  Require  Other Special Needs:______s assistance s a in feeding, wheelchair dressing, or toileting  Must  Has ______have immobility medications administered  Is  Has visually development impaired- al disability requires assistance

G. SERVICES NEEDED: Check all services needed by client at time of intake.  Shelter  Emotion  Child  Medical Advocacy al/Counselin Care g  Housing  Individu  Legal  Crisis Intervention al Support Services (child)  Financi  School  Employ  Transportation al Advocacy ment (child)  Referral  Group  Legal  Parent/Child Support Activity Advocacy (child)  Lock  Educati  Medical  Community Advocacy (child) up/Board up on Services  Therapy

H. RESIDENC E: Address:

City/Town Township County State Zip Code (Enter UK for Unknown and NR for Not reported) Home Phone (_____)_____-______Work Phone (_____)_____-______Emergency Contact: (____)_____- ______Page 4 of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs

Type of Residence (IMMEDIATELY prior to coming to dv shelter/transitional housing program) (shelter clients only)

 Emerge  Substan  Staying/  Place not meant for habitation ncy ce abuse living shelter(oth treat. w/family er dv or facility member homeless)

 Transiti  Jail/priso  Staying/  Other onal n/juvenile living housing- detention w/friend homeless ctr

 Perm.  Room/a  Hotel/m  Unknown housing for pt/house otel paid formerly rented for w/o homeless emergency shelter voucher

 Psychiat  Apt/hou  Foster  Not Reported ric se owned care hospital/fac home/grou ility p home

Length of stay in previous place (place indicated above) (shelter clients only)

 One  One  1-3  More  One  Unknown week or week to months than 3 year or less one month months, up longer to 1 year PREVIOUS SERVICE USE (shelter clients only): In The Last Year…. 1--Have you used another domestic violence shelter in this part of IL? YES NO If yes, about how long ago (approx date): ______2--Have you used another homeless shelter in this part of IL? YES NO If yes, about how long ago (approx date): ______

I. OFFENDE R Name:______Soc.Sec.#:______-______-______County/State:______INFORMA TION: Birth DOC D. Ca E. Age (at victim intake):______Dat #:______se e:______#: _/__ __ _/______Race:  African  Asian  Biracial  Hispani  Native  Other  Unknow  White American c Amer. n Gender:  Fe  M  Ot m al he al e r e Relations hip to Client:

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs  Husban  Mother’  Girlfrien  Female Child/Grandchild d s Boyfriend d  Ex-  Male  Ex-  Other Female Relative husband Stranger girlfriend  Boyfrie  Male  Female  Female Stranger nd Child/Grandc Acquaintanc hild e  Ex-  Other  Female  Unknown boyfriend Male Shares Relative Household  Male  Male  Mother  Same Sex Partner Acquaintanc Shares e Household  Father  Wife  Female Friend  Male  Ex-Wife  Father’s Friend Girlfriend  No  Supervi  Not an  Unknow Visitatio sed  Unsupervised Visitation Visitation: n Issue Visitatio n Allowed n If there are police and/or state’s attorney charges against the offender, document those on the Medical Criminal Justice Information Form.

J. ELIGIBILIT Y DETERMIN ATION/PR OGRAM RESPONS E: Eligible for Services: 1. Based on the circumstances documented above, it is reasonable to conclude that the individual identified herein and accompanying children, if any, is subject to, or at risk of, abuse and is eligible to receive domestic violence services on the basis for the need for protection. Immediate Program Response: a.1) Accepted as client in on-site residence a.2) Accepted as client in emergency shelter a.3) Accepted client as non-residential client a.4) Referred to another program (name)______2. Based on information received at the time of intake, I conclude this individual is not eligible for services. Intake Date:______Worker:______

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs I understand that by my signature, I am verifying the above information and requesting service for ____myself; _____myself and family. I also understand that I have a right to appeal and have a fair hearing of any grievance.

Client Signature:______Date:______

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs MEDICAL/CRIMINAL JUSTICE -- VICTIM DOCUMENTATION INFORMATION MEDICAL

Visit medical  Not  No  Unknown  Yes facility? Reported Treated For  Not  No  Unknown  Yes Injuries? Reported  Did not  Required Seriousness require hospital  Unknown Of Injuries: hospital admission admission  Not Location of Photos Taken:  No  Unknown  Yes Reported Photos:______Type of  Private  Trauma Medical  Clinic  ER  None  Other  Unknown Facility: Physician Ctr. Evidence Kit  Not  No  Unknown  Yes Used? Reported Other Family Problems:______

The Offender  Threw (check all that something  Beat up your victim apply): at your victim  Pushed, grabbed or  Choked your victim shoved your victim  Slapped  Threatened your victim with a knife or gun your victim  Kicked, bit or hit your  Used a knife or fired a gun victim with a fist  Hit or tried to hit your victim with something

ORDERS OF PROTECTION Originally Date Filed:___/___/___ Sought Order:  Granted  Denied  Pending  Unknown County:______Date Issued:___/___/______Type of Order:  Emergency  Interim  Plenary  Unknown Date Vacated:___/___/___

Forum:  Criminal  Civil  Unknown Original Date Of Expiration:___/_ Comments:______/___ Activity 1 Activity 2

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs  Violation  Violation W/Police Charge  EOP to  EOP to W/Police  Violation W/O Police Charge IOP Charge IOP  EOP to  Violation  EOP to Activity Date: ___/___/___ POP W/O Police POP New Expiration Date:___/___/___  IOP to Charge  IOP to POP POP Activity Date:  Extension ___/___/___  Extension  Modificatio New Expiration  Modificatio n Date:___/___/_ n __ Activity 3 Activity 4  Violation  Violation W/Police Charge  EOP to  EOP to W/Police  Violation W/O Police Charge IOP Charge IOP  EOP to  Violation  EOP to Activity Date: ___/___/___ POP W/O Police POP New Expiration Date:___/___/___  IOP to Charge  IOP to POP POP Activity Date:  Extension ___/___/___  Extension  Modificatio New Expiration  Modificatio n Date:___/___/_ n __

POLICE Date Reported to  Patrol  Detective Interview Police:___/___/ Interview ___

PROSECUTION  State’s  Trial Attorney  V/Witness Trial Type:  Bench  Jury  Unknown Scheduled Interview Court If results in  Prosecutio Appearance continuance,  Defense  Other ___/___/___ which type? n Court If results in  Prosecutio Appearance continuance,  Defense  Other ___/___/___ which type? n Court If results in  Prosecutio Appearance continuance,  Defense  Other ___/___/___ which type? n Court If results in  Prosecutio Appearance continuance,  Defense  Other ___/___/___ which type? n Court If results in  Prosecutio Appearance continuance,  Defense  Other ___/___/___ which type? n

V/W  Not Participate:  Yes  No Appropriat  Unknown e

of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs MEDICAL/CRIMINAL JUSTICE -- OFFENDER CRIMINAL JUSTICE DOCUMENTATION F. POLICE Police Department:______Report Number:______

Arrest Made?  No  Not Reported  Unknown  Yes Date of Arrest:___/___/___ Police Charge Date of Charges: ___/___/______Charge Type:  Felony  Misdemeanor  Unknown Police Charge Date of Charges: ___/___/______Charge Type:  Felony  Misdemeanor  Unknown G. PROSECUTION Charges Filed?  No  Not Reported  Unknown  Yes Charge Type:  Felony  Misdemeanor  Unknown State’s Attorney Charge: Charge Date:___/___/______ Convicted,  Dismissed, Disposition:  Acquitted Lesser Victim Didn’t  Mistrial  Pled Guilty, Original Charge Charge Show  Dismissed,  Charges  Dismissed,  Other:______Want Of  Stricken On Leave Dropped Fines ____ Prosecution  Pled Guilty,  Dismissed,  Convicted  Hung Jury Lesser  Unknown Other Reason Charge  Conditional  Juvenile  Not  Probation Sentence 1: Discharge Detention Sentenced Sentence  Juvenile  Fines  Other  Restitution Date:___/___/___ Probation Sentenced for: Yrs_____Mo_____  Jail  Mandated  Prison  Supervision  Unknown Days____ Couns.  Conditional  Juvenile  Not Sentence 2: Discharge Detention Sentenced  Probation Sentence  Juvenile  Fines  Other  Restitution Date:___/___/___ Probation Sentenced for: Yrs_____Mo_____  Jail  Mandated  Prison  Supervision  Unknown Days____ Couns.  Conditional  Juvenile  Not Sentence 3: Discharge Detention Sentenced  Probation Sentence  Juvenile  Fines  Other  Restitution Date:___/___/___ Probation Sentenced for: Yrs_____Mo_____  Jail  Mandated  Prison  Supervision  Unknown Days____ Couns. Charge Type:  Felony  Misdemeanor  Unknown State’s Attorney Charge: Charge Date:___/___/______ Convicted,  Dismissed, Disposition:  Acquitted Lesser Victim Didn’t  Mistrial  Pled Guilty, Original Charge Charge Show  Dismissed,  Charges  Dismissed,  Other:______Want Of  Stricken On Leave Dropped Fines ____ Prosecution  Pled Guilty,  Dismissed,  Convicted  Hung Jury Lesser  Unknown Other Reason Charge  Conditional  Juvenile  Not Sentence 1: Discharge Detention Sentenced  Probation Sentence  Juvenile  Fines  Other  Restitution Date:___/___/___ Probation Page 10 of 11 ADULT CLIENT INTAKE/ELIGIBILITY DETERMINATION FORM Residential Shelter Programs Sentenced for: Yrs_____Mo_____  Jail  Mandated  Prison  Supervision  Unknown Days____ Couns.  Conditional  Juvenile  Not Sentence 2: Discharge Detention Sentenced  Probation Sentence  Juvenile  Fines  Other  Restitution Date:___/___/___ Probation Sentenced for: Yrs_____Mo_____  Jail  Mandated  Prison  Supervision  Unknown Days____ Couns.  Conditional  Juvenile  Not Sentence 3: Discharge Detention Sentenced  Probation Sentence  Juvenile  Fines  Other  Restitution Date:___/___/___ Probation Sentenced for: Yrs_____Mo_____  Jail  Mandated  Prison  Supervision  Unknown Days____ Couns.

Client ID______ First Contact Date______ Case Close Date:______

Client ID First Contact Date Case Close Date:__