Victim Assistance

Sherri Denese Jackson Foundation For the Prevention of Domestic Violence, Inc.
emergency housing/shelter referral application

Please take your time to complete this general application and answer the questions as completely as possible. In order for your application to be considered, all questions must be answered completely. (*If there is no answer to provide please enter N/A)

* Indicates required field

Date *

Name *

First

Last

Date of Birth (mm/dd/yyyy) *

Age *

Phone Number *

Email *

Name of shelter where you are currently residing: *

Address of shelter if known *

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City

State

Zip Code

Country

Address prior to moving into shelter *

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City

State

Zip Code

Country

Previous cities of residence *

Areas that you frequent or have been employed? *

What cities/areas do your friends or family members live in? (list all known locations) *

What city/area do the batterer's friends or family members live in? *

Marital Status *

Dates if applicable of: marriage, separation or divorce: *

Were you living with the batter before you entered the shelter? *

Primary language *

Secondary language? *

Emergency Contact information: *

First

Last

Emergency contact address *

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City

State

Zip Code

Country

Phone Number *

Relationship *

Please provide names of children, date of birth, sex, age seeking shelter with you. What is the father's name? Is father a batterer? *

Do you hope/expect that your children will join you at the shelter during your stay? Please explain: *

Do you have other children that are not living with you? If yes, list below: *

Could you be pregnant? If yes, how many months? *

Do you or your children have any special needs or require special accommodations? *

ABUSE HISTORY

Batterer's name *

First

Last

Batterer's date of birth (mm/dd/yyyy) *

Batterer's address *

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City

State

Zip Code

Country

Batterer's age *

Is the batterer looking for you? How do you know? *

What areas does your batterer frequent? *

Is the batterer currently employed? *

If yes, list employer, type of work and what area does the batterer work in? *

Where has batterer worked in the past? *

Has the batterer been in contact with your family/friends since you entered the shelter? If yes, when? *

Have you left your partner in the past? If yes, how many times? How long were you away each time? *

Describe the abuse within your relationship (include type, length, and frequency of abuse) *

Has your batterer ever found you when you left in the past? If yes, please explain: *

Has the abuse ever resulted in you requiring medical attention? If yes, please explain *

Does your batterer own or have access to any weapons? If yes, please explain *

Have the police ever been involved? If yes explain *

Does your batterer have a history of drug/alcohol abuse? If yes, please list type and frequency or usage. *

SHELTER HISTORY

Names of shelters previously lived: *

What have you accomplished at the shelter so far? *

Describe how satisfied you are at your current shelter? *

What is the most difficult part about living in the shelter? What would you like to gain from this process?? *

LEGAL SITUATION

Do you currently have a restraining order? Expiration date: *

Are you currently involved in any legal actions? If yes, please explain *

Is there a standing custody or visitation order currently in place? If yes, please explain *

Are you seeking a divorce? *

Seeking custody/visitation *

List any upcoming court dates and locations: *

Do you currently have a lawyer? Name and location: *

Have you ever been arrested or convicted of a crime? If yes, please explain *

children

Do you currently have an open case with Department of Children and Family Services (DCFS)? *

Name and phone number of current DCFS caseworker? *

Have you ever had a case opened in the past? If yes, please explain: *

Automobile

Are you bringing a car to the shelter? If no, skip to next section. If yes: whose name is that car registered in? Please list make, model, year, color, license plate *

Do you own or make payments on the car? *

financial
employment information

Please explain income (how long/amount) *

If employed are you willing to request a transfer or change jobs if determined that it is unsafe for you to return to your previous employer? If no please explain: *

what are your goals

What do you think our transitional program can offer you? *

What are your three main goals during your transitional stay? *

What are your three main goals after your transitional stay? *

What are you three main long term goals? (A 3 to 5 year plan) *

What goals do you have for your children during your stay in a transitional program? *

By checking the box below you acknowledge that the information is accurate and true to the best of your knowledge. *

I agree that the information provided is accurate and true.

Submit