Family Violence Intervention Program Intake Form

Participant's Name

First, Middle & Last

Birth Date

Race

Participant's Current Address

City, State & Zip Code

Participant Contact Number

Participant's Email address

Participant's Driver's License Number

State License was Issued

Emergency Contact's Name

First, Middle & Last

Emergency Contact's Relationship

Emergency Contact's Phone Number

Orientation Date

Program Start Date:

Choose the date you want to attend your first class.

Program End Date:

24 sessions total - do not include the orientation session.

Do you have a copy of the police report? You must obtain a copy of the police report prior to the first class.

Yes

Probation Officer

Name

County of Referral

Date Ordered to Attend FVIP

Referral Source:

Who sent you to the program?

Probation Officer's Email

Probation Officer's Phone #

Participant's Vehicle:

Year, Make & Model of Vehicle

Which of these apply to you? Check all that apply.

Probation

Temporary Protection Order

Pre-trial Diversion

Misdemeanor

Felony

Bond

No Contact Order

Name of Participant's Employer

Victim's Name

First, Middle & Last Name

Victim's Address

City, State & Zip Code

Victim's Phone Number

Participant & Victim's Relationship

Be specific

Victim's Birthdate

Victim's Race

Victim's Eye Color

Current Living Arrangements

Live with Victim No, Moved Out Live alone Live with Parent Live with a friend Other

Describe the Incident between you and the victim that led to your arrest:

List all of your charges and arrests (include the year). Begin with this incident.

If you have access to weapons in your home, please list the type and location for each weapon.

Please share any additional information you would like to share or type N/A in the box.

Your information will be encrypted.

Family Violence Intervention Program Intake Form

East Coweta DUI School & Risk Reduction Center, LLC.