Women’s Commission

700 North Tryon Street

Charlotte, NC 28202

Teen Dating Application

Today’s Date:

Who referred you to the Women’s Commission?

Client Name:

Last Name First MI

Race: Age: Gender:

Date of Birth: Social Security #:

Phone: (W) (H) Is it safe to call you at home? _______

If not where can we contact you?

Address:

Street Address City Zip Code County

School attending: Grade:

Does your partner attend the same school? Yes No

Name of Client’s Partner: Race: Age:

Last First MI

Relationship Status Currently: Dating?_____ Separated? _____ Living Together? ___

Previously Lived Together?_____

Do you currently have a 50-B (Domestic Violence Restraining Order)? _____Yes______No

Criminal Charges: ___Assault on a female ___B&E ____Assault with a deadly weapon ____Stalking ____Destruction of property

Please check all that apply ___Harassing Phone Calls ___Other: ________

___Violation of Restraining Order ___Other: _____________

Offense Court Date/Time Courtroom

Court Date(s):

Have you and your partner received counseling/services together from:

___Mediation ___School Counselor ____Pastor/Priest

___Other: _______________________________

Current Employment:

Name of Employer:

Hours Per Week

Shift Worked:________ Hourly Wage:_________________

Children’s Information: (If Applicable)

Number of Children: _____ Number of Children With Partner: ____

Name (Last, First) DOB Social Security # Race/Gender School

Parent/Guardian Name:

Last Name First MI

Race: Age: Relationship to Client:

Phone: (W) (H) Is it safe to call you at home? _______

If not where can we contact you?

Address:

Street Address City Zip Code County

I consent to receiving counseling services

Client Name

provided by the Women’s Commission Teen Dating Violence Program.

Client Signature Date

Parent/Guardian Signature Date

STAFF USE ONLY: ____ Dating Violence ____ Dating Violence (Children)

____ Crisis ____ Legal ____ Other


Mail To:

Mecklenburg County Women’s Commission

Attention: Intake Services

700 North Tryon Street

Charlotte, NC 28202

or

Fax: (704) 336-4198

Revised 9/2003