Victim Intake Form

00:00

Until your session expires

Your Details

Individual

Business/Organization

Business/Organization*

First Name*

Last Name*

Email*

Phone number*

Ext.

Work Mobile Home

Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

Country*

Additional Information For Your Victim Intake Form(s)

1 X Victim Intake Form

Reason for Assistance:

Optional

Race:

Optional

Ethnicity:

Optional

Referred By:

Optional

Characters Remaining: 500

Primary Language:

Optional

Characters Remaining: 500

Home City/State:

Optional

Characters Remaining: 500

Dress Size:

Optional

Characters Remaining: 500

Shoe Size:

Optional

Characters Remaining: 500

Do you have children?

Optional

How recent was the abuse/trafficking situation?

Optional

Characters Remaining: 500

Explain your current situation:

Optional

Characters Remaining: 2000

How long have you been subjected to this situation?

Optional

Characters Remaining: 500

Is your family unsafe and/or unhealthy?

Optional

Characters Remaining: 500

Is there an open or pending case against your abuser/trafficker?

Optional

If other, please specify with the given space below:

Optional

Characters Remaining: 500

What state?

Optional

Characters Remaining: 500

Are you currently (or recently) affiliated with a gang?

Optional

Is your trafficker(s) still a threat to you?

Optional

Characters Remaining: 500

Have you been Diagnosed with Mental Health?

Optional

If other, please specify with the given space below:

Optional

Characters Remaining: 500

How long ago were you diagnosed?

Optional

Characters Remaining: 500

What was the earliest age you were diagnosed?

Optional

Characters Remaining: 500

Do you have medical insurance?

Optional

Do you have/need any assistive devices? If yes, explain:

Optional

Characters Remaining: 500

Do you have a criminal history?

Optional

Do you believe you have an addiction issue?

Optional

When was the last date you used any of the above?

Optional

The longest period of sobriety in the past year?

Optional

Characters Remaining: 500

Do you want services to address your recovery?

Optional

Characters Remaining: 500

What do you need and/or expect from Dock Ellis Foundation?

Optional

Characters Remaining: 500

Have you ever been evicted, denied and/or removed from services? (Dates, reasons)

Date:

Optional

Explain:

Optional

Characters Remaining: 2000

Do you have any special needs that Dock Ellis Foundation should be aware of?

Optional

Characters Remaining: 500

The Dock Ellis Foundation does not discriminate against any person on the basis of race, color, national origin, disability, or age (and any other bases you wish to include) in admission, treatment, or participation in its programs, services, and activities, or in employment, or on the basis of sex in its health programs and activities.

Optional

Check the box to confirm.

By clicking I agree to the terms.

Your Details

Additional Information For Your Victim Intake Form(s)

1 X Victim Intake Form

It looks like you're using an outdated browser, which cannot properly display this page. Please switch to a different browser such as Chrome, Firefox, Safari or Edge. You can download any of these supported browsers using the following links: