Intake Form / A2 /

Intake Date: ______New client: YES NO Name of Intake Officer: ______

Client name surname / Unique No
ID/REF No / DOB
Address
Contact Details / Cell: / Work: / Email:
Age group / 5-12 / 13-18 / 19-30 / 31- 40 / 41-50 / 51 and over
Sex Orientation / Male / Female / Transgender / Language
Nationality / Race / BA / BC / BI / W / R / A / U
Health Status / Good / Fair / Poor / Illnesses: / Diabetes / Asthma / Heart
High BP / HIV / TB / OTH
Disabilities / Sensory / Mental / Psychosocial / Physical / Intellectual / Medical
Marital status / Single / Common law / Married / Separated / Widowed / Divorce
No of children / 0 / 1 / 2 / 3 / 4 / 5 +
Employment status / Unemployed / Employed / Contract / Part-time / Casual
Economic status / Independent / Dependant / Occupation:
Name of next of kin / Contact No:
The client lives with / Biological / Foster / Grandparent / Sibling / Spouse / Partner / Other
Key population / M2M / Injecting Drug User / LGBTQI / Young Woman or girl 14-24 / Sex Worker / Other
Referral Agent / NPO / Self / Other GF programs / DSD / Other:

What has happened to you? Tick as many blocks as necessary.

Self harm / Suicidal thoughts / 1-1 / Suicidal behaviour / 1-2 / Self-inflicting / 1-3
Domestic violence / Physical / 2-1a / Economic / 2-1b / Mental / 2-1c / Sexual / 2-1d
Emotional / 2-1e / Verbal / 2-1f / Stalking / 2-1g
IPV / Physical / 2-1h / Economic / 2-1i / Mental / 2-1j / Sexual / 2-1k
Emotional / 2-1l / Verbal / 2-1m / Stalking / 2-1n
Child abuse neglect home / Physical / 2-2a / Deprivation
neglect / 2-2b / Sexual / 2-2c / Emotional / 2-2d / Mental / 2-2e
Sexual violence / Rape / 2-3a / Forcible oral copulation / 2-3b / Forcible fondling / 2-3c / Assault with object / 2-3d / Threat / 2-3e
Sexual harassment / 2-3f / Sodomy / 2-3g / Attempted rape / 2-3h / Attempted
sodomy / 2-3i / Gang rape / 2-3j
Social crime / Robbery / 2-4a / Armed robbery / 2-4b / Hi-jacking / 2-4c / Physical assault / 2-4d / Threats / 2-4e
Harassment/
Bullying / Physical assault / 2-4f / Threats / 2-4g / Cyber / 2-4h / Verbal / 2-4i / Stalking / 2-4j
Hate crime / Xenophobia / 2-5a / Racism / 2-5b / Corrective Rape / 2-5c / Political rape / 2-5d
Traumatic
Bereavement / Rape murder / 2-6a / Gang murder / 2-6b / Murder / 2-6c / Completed suicide / 2-6d / Drowning / 2-6e
Vigilante
Murder / 2-6f / Fire / 2-6g / Car accident / 2-6h
Organised crime / Gang assaults / 3-1a / Gang robbery / 3-1b / Witness / 3-1c / Human trafficking / 3-1d / Vigilantism / 3-1e
Torture / By state actors / 3-2a / By non state actors / 3-2b
Vicarious trauma / Secondary trauma frontline workers / 4-1 / Secondary trauma / 4-2 / Vicarious / 4-3
Reliving / Avoidance / Negative beliefs & feelings / Arousal-hyperarousal / Physiological responses
Nightmares / Withdrawn / Lack of trust / Sleeplessness, / Headaches
Violent fantasies / Numbing / Feeling of helplessness / Jumpy / Back aches
Distressing thoughts / Feeling isolated / Negative view of life/world / difficulty concentrating / Stomach aches
Flashbacks / Fear, Guilt, Self-blame, anger / Anxiety
Daydreaming / Depressed / Irritability
Client was abused by: / Partner / Ex Partner / Other:Specify

What help have your received thus far?

If you have seen a doctor or visited a hospital for this incident, who have you seen or which hospital?
In the case of rape, torture & physical assault, has the J88 been completed? / Yes / No / Declined
In the case of domestic violence, has the protection order been served? / Yes / No / Declined
Have you received Trauma counselling? / Yes / No / Declined
Would you like the Trauma Centre to refer you for medical assistance? / Yes / No / Declined
Have you laid a charge? / Yes / No / Declined
Current HIV Status / Known HIV + status and on treatment / Known HIV + status and not on treatment / Negative / Unknown / Undisclosed
Date of last test
I agree to HTS / Yes / No
Reason for not testing / Known status / Refuse to test / Client not ready / HTS Counsellor n/a / Other
Was client provided with modern contraception? / Yes / No
If yes / Female condom / Male condom / Other: Specify
Was client referred for modern contraception? / Yes / No / If yes, specify:
If no, specify / Client on another contraception / Client refused / Other specify:
Referral for services / Counsel / Legal / TCC / HTS / Adherence / Pap Smear/Breast / Mother 2 child transmission / Shelter / Other
Follow up
Yes/No
Consent and Limitations to Confidentiality Agreement
I, Mr/Mrs/Ms ...... hereby agree or allow my child …………………………………………
to participate in counselling sessions conducted by the Trauma Centre for Survivors of Violence and Torture’s counsellors. During the counselling process, I/my child will not be under the influence of drugs (excluding prescribed medication) and alcohol nor will I/my child carry any weapons.I understand that confidential information shared with the counsellor can only be disclosed upon my writtenrequest and if required by referral parties involved in my treatment. I understand that the Trauma Centre is legally obliged to disclose confidential information without my consent if it is necessary to protect myself and/or others from harm. I understand that children aged over 12 have the same right to confidentiality and consent as adults to treatment. I understand that children 12 & over have to consent for disclosure. I understand that the counsellors are bound by ethical principles regarding confidentiality and its limitations.I give the Trauma Centre permission to use selected information for research purposes only. Signed at ...... on ......
Client/Parent………………………….. Clinician: ……………………………