Client Information Form

To help us in determining which of our programs and services will best meet your needs, please complete this form as accurately as possible. If you hit “Exit” you will not be able to resume your work on the form. Once you hit “Submit” you will not be able to edit any information on the form. Therefore, we ask that you double-check all information on the form before hitting “Submit”. Thank you!

Full Name*
First Middle Last
Preferred Name
Date of Birth*
MM slash DD slash YYYY
Current Address*
Street Address Address Line 2 City State ZIP Code
Please Provide a Safe Phone Number*
What is the Best Time To Call You?

: Hours

Minutes

AM/PM
Please Provide a Safe Email Address
Does the abuser have access to your email or phone?
Abuser's Name*
First Middle Last
Abuser's Date of Birth*
MM slash DD slash YYYY
What is your relationship with the abuser?*
What is the approximate date of the last incident?*
MM slash DD slash YYYY
Please describe the most recent incident with your abuser.*
Approximately when did your relationship with the abuser begin?*
MM slash DD slash YYYY
Does the abuser know where you live or have access to your home?*
Please list your dependents.
Dependent 1 Name
First Middle Last
Dependent 1 Date of Birth*
MM slash DD slash YYYY
Dependent 2 Name
First Middle Last
Dependent 2 Date of Birth*
MM slash DD slash YYYY
Dependent 3 Name
First Middle Last
Dependent 3 Date of Birth*
MM slash DD slash YYYY
Dependent 4 Name
First Middle Last
Dependent 4 Date of Birth*
MM slash DD slash YYYY
Dependent 5 Name
First Middle Last
Dependent 5 Date of Birth*
MM slash DD slash YYYY
How many of these children do you and the abuser have in common?
Please enter a number from 0 to 99.
Are you receiving child support?*
Are you employed?*
Employer Name*
Employer Address*
Street Address Address Line 2 City State ZIP Code
Approximately when did you start your current job?*
MM slash DD slash YYYY
What is your monthly income?
Do you have other sources of income?*
If so, what source(s)?*
Does your monthly income cover your financial need?*
What is your monthly rent expense?*
What is your monthly utilities expense?*
What is your monthly grocery expense?*
What is your monthly childcare expense?*
What is your monthly transportation (gas) expense?*
What is your monthly counseling expense?*
What is the total of other monthly expenses?*
Please explain what the other expense is?
Total Monthly Expenses
$0.00
What type of assistance do you need?
Check all that apply.
- Legal Representation
- Individual or Family Counseling
- Support Group
- Escape from an Abuser
- Job Placement and resume Assistance
- Housing Assistance
- Court Advocate
- Food Assistance
- Mentoring
- Other
Please explain what other assistance you need:*
Are you currently living with your abuser?*
Have you ever filed a police report against your abuser?*
When did you file a police report against your abuser?*
MM slash DD slash YYYY
In what county did you file a police report against your abuser?
Do you need help obtaining an Order of Protection?*
Do you have an Order of Protection?
Do you have an attorney?*
What is the attorney’s contact information?*
What type(s) of adverse experiences have you had?*
Check all that apply.
- Intimate Partner/Domestic Abuse - Against You/Family Member (Emotional, Financial, Physical, or Sexual)
- Alcoholism (You/Family Member, Intimate Partner)
- History of Domestic Violence in Your Family
- Childhood Neglect
- Bullying
- Divorce (You/Family Member)
- Rape
- Sexual Assault
- Witness to Violence
- Homelessness
- Mental Illness (You/Family Member)
- Incarceration (You/Family Member)
- Substance Abuse
- None of the Above
Have you ever been treated for a mental illness?*
Please briefly describe your illness and treatment.
Are you involved with a faith community?*
How did you hear about The Women's Advocacy Center?
Signature:*
Your signature indicates you have read all information in this form and verified its accuracy to the best of your ability to do so. Giving false or misleading information may result in termination of services and where applicable we may pursue prosecution for any damages suffered by The Women’s Advocacy Center. Please allow up to 48 hours to receive a response to your form submission. If you have not received a response within 48 hours, please send an email to: contactus@womensac.org.
Date*
MM slash DD slash YYYY