JVH INTAKE QUESTIONNAIRE
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NAME 
 ADDRESS
EMAIL ADDRESS
PHONE NUMBER
DATE OF BIRTH
MM
/
DD
/
YYYY
MARTIAL STATUS
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AGE OF CHILD/CHILDREN LIVING WITH YOU.
I AM REQUESTING ASSISTANCE FOR THE FOLLOWING:
ARE YOU CURRENTLYEXPERIENCING DOMESTIC VIOLENCE?
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TYPE OF ABUSE:
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ARE YOU AND THE PERPETRATOR CURRENTLY LIVING IN THE SAME HOME?
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ARE YOU AND OR  YOUR CHILD/CHILDREN IN A SAFE PLACE?
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WHERE ARE YOU CURRENTLY LIVING?
HAVE YOU EVER BEEN IN AN ABUSIVE RELATIONSHIP IN THE PAST?
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HAVE YOU EVER RECEIVED COUNSELING?
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