______________________________ _______________ ___________________ Name Pronouns Cell Phone Number _________________________________ _________________ Intake Date/Time Staff/Interviewer ____________________ Accommodations Needed? Yes No If so, please describe:  Perpetrator Information of Presenting Experience: Gender: Race: Female African-American/Black Native Hawaiian/Pacific Male Asian Islander Transgender Latino(a)/Hispanic Other/Unknown Native American/Native White/Caucasian Alaskan Age: __________ Relationship: Acquaintance Other Household Member Caretaker (non-family) Parent Cohabitating Partner/Spouse Stepparent/Parent’s Dating (includes ex’s) Partner Dating partner Stranger Extended Family Unknown/Other Is there a Protective Order in effect? No If yes, attach a copy. Accompanying Child(ren) Information: Full Name: Age: Gender and Pronouns: ___________________________________ __________ ___________________ ___________________________________ __________ ___________________ ___________________________________ __________ ___________________
______________________________ _______________ ___________________ Name Pronouns Cell Phone Number _________________________________ _________________ Intake Date/Time Staff/Interviewer Accommodations Needed? Yes  No If so, please describe: ____________________ Perpetrator Information of Presenting Experience: Gender: Female Male Transgender Race: African-American/Black Asian Latino(a)/Hispanic Native American/Native Alaskan Native Hawaiian/Pacific Islander Other/Unknown White/Caucasian Age: __________ Relationship: Acquaintance Caretaker (non-family) Cohabitating Partner/Spouse (includes ex’s) Dating partner Extended Family Other Household Member Parent Stepparent/Parent’s Dating Partner Stranger Unknown/Other Is there a Protective Order in effect? No If yes, attach a copy. Accompanying Child(ren) Information: Full Name: Age: Gender and Pronouns: ___________________________________ __________ ___________________ ___________________________________ __________ ___________________ ___________________________________ __________ ___________________