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Client Intake Form

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Client Intake Form Cher-Ae Heights Indian Community of the Trinidad Rancheria Tribal Victim Assistance Program Client Intake 1) Client Information: ☐ Primary Victim ☐ Secondary Victim ☐ Non-Victim Name: __________________________________________________________________ Address: __________________________________________________________________ DOB: ___________ Age ______ Gender Identity: ☐ M ☐ F ☐ Other: ___________ Phone: __________________ Okay to leave a message at this number ☐ Yes ☐ No Emergency Contacts: ______________________________________________________ Name Phone Relationship ______________________________________________________ Name Phone Relationship Race/Ethnicity (check all that apply) ☐ AI/AN ☐ Hispanic/Latino ☐ Black/African American ☐ Native Hawaiian/Other Pacific Islander ☐ Asian ☐ White (Non-Latino) ☐ Other Race ☐ Multiple Races Enrolled Tribal Member: ☐ Yes ☐ No If yes, which Tribe: _________________________ 2) Initial Victimization Type: Indicate the primary victimization with a “P” all others with a check mark ☐ Adult physical assault (1) ☐ Human trafficking: Labor (16) ☐ Human trafficking: Sex (17) ☐ Adult sexual assault (2) ☐ Identity theft/fraud/financial crime (18) ☐ Adults sexually abused/assaulted as children (3) ☐ Kidnapping (non-custodial) (19) ☐ Arson (4) ☐ Bullying (verbal, cyber or physical) (5) ☐ Kidnapping (custodial) (20) ☐ Mass violence (domestic/international) (21) ☐ Burglary (6) ☐ Other vehicular victimization (e.g., hit and run) ☐ Child physical abuse or neglect (7) (22) ☐ Child pornography (8) ☐ Robbery (23) ☐ Child sexual abuse/assault (9) ☐ Stalking/harassment (24) ☐ Cyber-crimes (10) ☐ Survivors of homicide victims (25) ☐ Domestic and/or family violence (11) ☐ Teen dating victimization (26) ☐ DUI/DWI incidents (12) ☐ Terrorism (domestic/international) (27) ☐ Elder abuse or neglect (13) Gang Violence (14) ☐ Hate Crime: Racial/religious/gender/sexual ☐ ☐ Other: ___________________________ (28) orientation/other (15) 3) Special Classifications of Individuals: (Check all that apply) ☐ Deaf/hard of hearing ☐ Veterans ☐ Homeless ☐ Victims with disability: cognitive/physical/mental ☐ Immigrants/refugees/asylum seekers ☐ Victims with limited English proficiency ☐ LGBTQ/Two-Spirit persons ☐ Other: ___________________________ 4) Present Situation: History/nature of the situation: ________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Timeframe of the situation: _________________ ☐ Are you currently involved with Child Welfare Services: Yes ☐ No ☐ Are you currently involve with Adult Protective Services: Yes ☐ No 5) Services Requested: ☐ Yes ☐ No Child Welfare/Dependency Court Advocacy: Must be a Trinidad Rancheria Tribal member ☐ Yes ☐ No Victim Services: Must be a victim of a crime at some point in Clients lifetime ☐ Yes ☐ No Substance Use Disorder Services: Must be a victim of a crime at some point in Clients lifetime X Client signature Date Office Use: ☐ New ☐ Returning Date Received: ____________ Staff initials: ________ Personnel assigned ______________________ Staff initials: ________ Page 2 of 2 .
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