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

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

Sex: / q  Female / q  Male / q  Other
3. Age at First Contact: ______
4.  Ethnicity: / q  Non-Hispanic/Non-Latino / q  Hispanic/Latino / q  Unknown
5.  Race: Check as many as apply / q  American Indian or Alaska Native / q  Asian / q  Black/African American / q  Native Hawaiian/Other Pacific Islander / q  White / q  Unknown
6.  Veteran’s Status (shelter clients only): / q  No / q  Yes / q  Unknown / q  Not Reported (e.g., client didn’t want to provide)
7.  Employment: / q  Full Time / q  Not Employed / q  Part Time / q  Unknown
8.  Education: / q  College Grad or More / q  High School Grad / q  No High School / q  Some College
q  Some High School / q  Unknown
9.  Marital Status: / q  Common Law / q  Divorced / q  Legally Separated / q  Married / q  Single / q  Unknown / q  Widowed
10.  Pregnant: / q  No / q  Not Reported / q  Unknown / q  Yes / q  Not Applicable (male clients only)
11.  Number of Children: ______Name Sex Age
B.  PRIMARY PRESENTING
ISSUE (choose ONE): / q  Emotional DV / q  Physical DV / q  Sexual DV / Primary Offense Date: ______/______/______
1. Offense Location: / q  Car / q  Offender’s Home / q  Other Private Location / q  Other Public Location / q  Park / q  School
q  Shared Home / q  Street / q  Victim’s Home / q  Victim’s Work / q  Other:______
2. Other Presenting Issues: / q  Rape/Sexual Assault / q  Adult survivor incest/ child sexual assault / q  Stalking / q  Harassment / q  Child sexual assault / q  Child abuse
(Check as many as apply) / q  Child neglect / q  Date rape / q  Drugged / q  Home invasion / q  Hate crime / q  Physical DV
q  Sexual DV / q  Emotional DV / q  Domestic battery / q  Aggravated dom. battery / q  Violation of OP / q  Elder abuse
q  Homicide / q  Attempted homicide / q  DUI/DWI / q  Other assault / q  Battery / q  Assault/battery
q  Burglary / q  Robbery / q  Other offense against person / q  Other offense / q  Unknown offense
C.  CLIENT INCOME SOURCE(S): Check as many as apply AND indicate MONTHLY amnt. / q  Earned Income $______/ q  Worker compensation $______/ q  Pension from former job $______
q  Unemployment Insurance$______/ q  TANF $______/ q  Child Support $______
q  SSI $______/ q  Soc Sec Disability $______
q  General assistance $______/ q  Alimony/other spouse income $______
q  Veterans disability pay $______/ q  Retirement income/Soc. Security$______/ q  Other Source______$______
q  Private disability insurance$______/ q  Veteran’s pension $______/ q  No financial resources / q  Unknown (-1 unknown; -2 not reported)
D. NONCASH BENEFITS/HEALTH INSURANCE:
1. Non Cash Benefits:
q  Food Stamps/food benefit card (Link Card) / q  TANF Transportation / q  Other Source
q  Special Supplemental nutrition (WIC) / q  Other TANF funded services / q  No Non Cash benefits
q  TANF Child Care services / q  Section 8, public housing, rent assistance / q  Unknown
2. Health Insurance
q  Medicaid health insurance (18 and older only) / q  State children’s health insurance (Children’s Medicaid) / q  Private health insurance
q  Medicare health insurance / q  Veteran’s administration med services / q  No health insurance
q  Unknown
E. REFERRAL SOURCE:
1. Referred From:
q  Police / q  DCFS / q  Legal System / q  Circuit Clerk / q  Other Project / q  Self
q  Hospital / q  Medical Advocacy Program / q  Private Attorney / q  Clergy / q  Telephone / q  Friend
q  Medical / q  Social Service Program / q  State’s Attorney / q  Education System / q  Relative / q  Media
q  Public Health / q  Hotline / q  Other Referrals:______
2. Referred To:
q  Police / q  Medical / q  Medical Advocacy Program / q  Legal System / q  State’s Attorney / q  Clergy
q  Hospital / q  Public Health / q  Social Service Program / q  Private Attorney / q  Circuit Clerk / q  Education System
q  Other Project / q  Other Referrals:______
F. SPECIAL NEEDS (as many as apply): / q  No special needs indicated / q  Unknown / q  Not Reported
q  Is hearing impaired / q  Has limited English (primary language:______) / q  Requires special diet
q  Requires assistance in feeding, dressing, or toileting / q  Requires a wheelchair / q  Other Special Needs:______
q  Must have medications administered / q  Has immobility / ______
q  Is visually impaired-requires assistance / q  Has developmental disability
G. SERVICES NEEDED: Check all services needed by client at time of intake.
q  Shelter / q  Emotional/Counseling / q  Child Care / q  Medical Advocacy
q  Housing / q  Individual Support (child) / q  Legal Services / q  Crisis Intervention
q  Financial / q  School Advocacy (child) / q  Employment / q  Transportation
q  Referral / q  Group Activity (child) / q  Legal Advocacy / q  Parent/Child Support
q  Lock up/Board up / q  Education / q  Medical Services / q  Community Advocacy (child)
q  Therapy
H. RESIDENCE:
Address:
City/Town Township County State Zip Code (Enter UK for Unknown and NR for Not reported)
Home Phone (_____)_____-______Work Phone (_____)_____-______Emergency Contact: (____)_____-______
Type of Residence (IMMEDIATELY prior to coming to dv shelter/transitional housing program) (shelter clients only)
q  Emergency shelter(other dv or homeless) / q  Substance abuse treat. facility / q  Staying/living w/family member / q  Place not meant for habitation
q  Transitional housing-homeless / q  Jail/prison/juvenile detention ctr / q  Staying/living w/friend / q  Other
q  Perm. housing for formerly homeless / q  Room/apt/house rented / q  Hotel/motel paid for w/o emergency shelter voucher / q  Unknown
q  Psychiatric hospital/facility / q  Apt/house owned / q  Foster care home/group home / q  Not Reported
Length of stay in previous place (place indicated above) (shelter clients only)
q  One week or less / q  One week to one month / q  1-3 months / q  More than 3 months, up to 1 year / q  One year or longer / q  Unknown
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. OFFENDER INFORMATION: / Name:______Soc.Sec.#:______-______-______County/State:______

Birth Date:___/___/___

/ DOC #:______ /

Case #:______

/

Age (at victim intake):______

Race: / q  African American / q  Asian / q  Biracial / q  Hispanic / q  Native Amer. / q  Other / q  Unknown / q  White
Sex: / q  Female / q  Male
Relationship to Client:
q  Husband / q  Mother’s Boyfriend / q  Girlfriend / q  Female Child/Grandchild
q  Ex-husband / q  Male Stranger / q  Ex-girlfriend / q  Other Female Relative
q  Boyfriend / q  Male Child/Grandchild / q  Female Acquaintance / q  Female Stranger
q  Ex-boyfriend / q  Other Male Relative / q  Female Shares Household / q  Unknown
q  Male Acquaintance / q  Male Shares Household / q  Mother / q  Same Sex Partner
q  Father / q  Wife / q  Female Friend
q  Male Friend / q  Ex-Wife / q  Father’s Girlfriend
Visitation: / q  No Visitation Allowed / q  Not an Issue / q  Supervised Visitation / q  Unknown / q  Unsupervised Visitation
If there are police and/or state’s attorney charges against the offender, document those on the Medical Criminal Justice Information Form.
J. ELIGIBILITY DETERMINATION/PROGRAM RESPONSE:
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:
1)  Accepted as client in on-site residence
2)  Accepted as client in emergency shelter
3)  Accepted client as non-residential client
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 Worker:______/ Date:______
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:______


MEDICAL/CRIMINAL JUSTICE -- VICTIM DOCUMENTATION INFORMATION

MEDICAL

Visit medical facility? / q  No / q  Not Reported / q  Unknown / q  Yes
Treated For Injuries? / q  No / q  Not Reported / q  Unknown / q  Yes
Seriousness Of Injuries: / q  Did not require hospital admission / q  Required hospital admission / q  Unknown
Photos Taken: / q  No / q  Not Reported / q  Unknown / q  Yes / Location of Photos:______
Type of Medical Facility: / q  Clinic / q  ER / q  None / q  Other / q  Private Physician / q  Trauma Ctr. / q  Unknown
Evidence Kit Used? / q  No / q  Not Reported / q  Unknown / q  Yes
Other Family Problems:______
The Offender (check all that apply): / q  Threw something at your victim / q  Beat up your victim
q  Pushed, grabbed or shoved your victim / q  Choked your victim
q  Slapped your victim / q  Threatened your victim with a knife or gun
q  Kicked, bit or hit your victim with a fist / q  Used a knife or fired a gun
q  Hit or tried to hit your victim with something

ORDERS OF PROTECTION

Originally Sought Order: / q  Granted / q  Denied / q  Pending / q  Unknown / Date Filed:___/___/___
County:______/ Date Issued:___/___/___
Type of Order: / q  Emergency / q  Interim / q  Plenary / q  Unknown / Date Vacated:___/___/___
Forum: / q  Criminal / q  Civil / q  Unknown
Original Date Of Expiration:___/___/___ / Comments:______
Activity 1 / Activity 2
q  EOP to IOP
q  EOP to POP
q  IOP to POP
q  Extension
q  Modification / q  Violation W/Police Charge
q  Violation W/O Police Charge
Activity Date: ___/___/___
New Expiration Date:___/___/___ / q  EOP to IOP
q  EOP to POP
q  IOP to POP
q  Extension
q  Modification / q  Violation W/Police Charge
q  Violation W/O Police Charge
Activity Date: ___/___/___
New Expiration Date:___/___/___
Activity 3 / Activity 4
q  EOP to IOP
q  EOP to POP
q  IOP to POP
q  Extension
q  Modification / q  Violation W/Police Charge
q  Violation W/O Police Charge
Activity Date: ___/___/___
New Expiration Date:___/___/___ / q  EOP to IOP
q  EOP to POP
q  IOP to POP
q  Extension
q  Modification / q  Violation W/Police Charge
q  Violation W/O Police Charge
Activity Date: ___/___/___
New Expiration Date:___/___/___

POLICE

Date Reported to Police:___/___/___ / q  Patrol Interview / q  Detective Interview

PROSECUTION

q  State’s Attorney Interview / q  V/Witness / q  Trial Scheduled / Trial Type: / q  Bench / q  Jury / q  Unknown
Court Appearance ___/___/___ / If results in continuance, which type? / q  Defense / q  Prosecution / q  Other
Court Appearance ___/___/___ / If results in continuance, which type? / q  Defense / q  Prosecution / q  Other
Court Appearance ___/___/___ / If results in continuance, which type? / q  Defense / q  Prosecution / q  Other
Court Appearance ___/___/___ / If results in continuance, which type? / q  Defense / q  Prosecution / q  Other
Court Appearance ___/___/___ / If results in continuance, which type? / q  Defense / q  Prosecution / q  Other
V/W Participate: / q  Yes / q  No / q  Not Appropriate / q  Unknown


MEDICAL/CRIMINAL JUSTICE -- OFFENDER CRIMINAL JUSTICE DOCUMENTATION

POLICE

Police Department:______Report Number:______
Arrest Made? / q  No / q  Not Reported / q  Unknown / q  Yes / Date of Arrest:___/___/___
Police Charge Date of Charges: ___/___/___
______
Charge Type: / q  Felony / q  Misdemeanor / q  Unknown
Police Charge Date of Charges: ___/___/___
______
Charge Type: / q  Felony / q  Misdemeanor / q  Unknown

PROSECUTION

Charges Filed? / q  No / q  Not Reported / q  Unknown / q  Yes
Charge Type: / q  Felony / q  Misdemeanor / q  Unknown
State’s Attorney Charge: Charge Date:___/___/___
______
Disposition: / q  Acquitted / q  Convicted, Lesser Charge / q  Dismissed, Victim Didn’t Show / q  Mistrial / q  Pled Guilty, Original Charge
q  Charges Dropped / q  Dismissed, Fines / q  Dismissed, Want Of Prosecution / q  Other:______/ q  Stricken On Leave
q  Convicted / q  Dismissed, Other Reason / q  Hung Jury / q  Pled Guilty, Lesser Charge / q  Unknown
Sentence 1: / q  Conditional Discharge / q  Juvenile Detention / q  Not Sentenced / q  Probation
Sentence Date:___/___/___ / q  Fines / q  Juvenile Probation / q  Other / q  Restitution
Sentenced for: / Yrs_____Mo_____Days____ / q  Jail / q  Mandated Couns. / q  Prison / q  Supervision / q  Unknown
Sentence 2: / q  Conditional Discharge / q  Juvenile Detention / q  Not Sentenced / q  Probation
Sentence Date:___/___/___ / q  Fines / q  Juvenile Probation / q  Other / q  Restitution
Sentenced for: / Yrs_____Mo_____Days____ / q  Jail / q  Mandated Couns. / q  Prison / q  Supervision / q  Unknown
Sentence 3: / q  Conditional Discharge / q  Juvenile Detention / q  Not Sentenced / q  Probation
Sentence Date:___/___/___ / q  Fines / q  Juvenile Probation / q  Other / q  Restitution
Sentenced for: / Yrs_____Mo_____Days____ / q  Jail / q  Mandated Couns. / q  Prison / q  Supervision / q  Unknown
Charge Type: / q  Felony / q  Misdemeanor / q  Unknown
State’s Attorney Charge: Charge Date:___/___/___
______
Disposition: / q  Acquitted / q  Convicted, Lesser Charge / q  Dismissed, Victim Didn’t Show / q  Mistrial / q  Pled Guilty, Original Charge
q  Charges Dropped / q  Dismissed, Fines / q  Dismissed, Want Of Prosecution / q  Other:______/ q  Stricken On Leave
q  Convicted / q  Dismissed, Other Reason / q  Hung Jury / q  Pled Guilty, Lesser Charge / q  Unknown
Sentence 1: / q  Conditional Discharge / q  Juvenile Detention / q  Not Sentenced / q  Probation
Sentence Date:___/___/___ / q  Fines / q  Juvenile Probation / q  Other / q  Restitution
Sentenced for: / Yrs_____Mo_____Days____ / q  Jail / q  Mandated Couns. / q  Prison / q  Supervision / q  Unknown
Sentence 2: / q  Conditional Discharge / q  Juvenile Detention / q  Not Sentenced / q  Probation
Sentence Date:___/___/___ / q  Fines / q  Juvenile Probation / q  Other / q  Restitution
Sentenced for: / Yrs_____Mo_____Days____ / q  Jail / q  Mandated Couns. / q  Prison / q  Supervision / q  Unknown
Sentence 3: / q  Conditional Discharge / q  Juvenile Detention / q  Not Sentenced / q  Probation
Sentence Date:___/___/___ / q  Fines / q  Juvenile Probation / q  Other / q  Restitution
Sentenced for: / Yrs_____Mo_____Days____ / q  Jail / q  Mandated Couns. / q  Prison / q  Supervision / q  Unknown

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