KFJC Victim Intake Form This form is for requesting services and is not an order of protection. The agency partner you selected will contact you during normal business hours. If you are in immediate danger, call 911. 1. Victim InformationPersonal InformationName(Required) First Last New or Returning Client(Required)Select OneNew ClientReturning ClientAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Race(Required)Select OneAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMiddle Eastern or North African (MENA)MultiracialNative Hawaiian or Other Pacific IslanderWhiteGender(Required)Select OneFemaleMaleNon-BinaryTransgender WomanTransgender ManGenderfluidRelationship to the Unsafe Person(Required)Select OneSingleMarriedDivorcedSeparatedIn a Domestic PartnershipWidowedDatingEngagedIntimate PartnerRoommateDate of Birth(Required) MM slash DD slash YYYY Safe Phone(Required)Safe Email(Required) Contact Method(Required)Select OneEmailTextCallPrimary Language(Required)Interpreter Needed(Required)Select OneYesNoVeteran(Required)Select OneYesNoAge Range(Required)Select OneUnder 1818-24 years25–34 years35–44 years45–54 years55 or olderAnnual Household Income(Required)Select One$0-20k$20-35k$35-50k$50k+Emergency ContactEmergency Contact Name(Required) First Last Relationship(Required)Phone(Required)Safety ConcernsAre there firearms in the home?(Required)Select OneYesNoAre the firearms locked away?(Required)Select OneYesNoHas choking/strangulation occurred?(Required)Select OneYesNo2. Children Under 18Click the Plus Icon to Add Additional ChildrenNameDate of BirthResides With?Gender?School/Daycare Add Remove3. Unsafe Person Information: Who are you here to talk about?Click the Plus Icon to Add Additional Unsafe People(Required)NameRaceGenderPhoneDate of BirthAdditional Details Add RemoveUnsafe Person/People Might Flee Check to Add Details of Unsafe Person's Potential Location(s) Click the Plus Icon to Add Additional Unsafe PeopleName of Unsafe PersonLocation Unsafe Person May Be At NowUnsafe Person Might Flee To (Name, Phone) Add RemovePolice Report Check to Add Police Report Number Police Report #Unsafe Person/People's Address Same as Victim Add Address/Addresses Click the Plus Icon to Add Additional AddressesName of Unsafe PersonStreet AddressCityStateZip Code Add RemovePhysical Appearance Check to Add Physical Appearance Details for Unsafe Person/People Click the Plus Icon to Add Additional Unsafe PeopleName of Unsafe PersonHeightWeightEye ColorHair ColorFacial Hair (e.g., beard, mustache, clean-shaven)Distinguishing Marks (e.g., scars, tattoos, birthmarks, piercings)Complexion/Skin ToneBuild/Body Type (e.g., slim, athletic, heavyset) Add RemoveEmployment History Check to Add Employment History Details for Unsafe Person/People Click the Plus Icon to Add Additional JobsName of Unsafe PersonEmployer NameSupervisor Name Add RemoveCar Description Check To Add Description of the Unsafe Person/People's Car(s) Click the Plus Icon to Add Additional CarsName of Unsafe Person Who Owns This CarMakeModelColorYearTag Number Add RemoveRights and Confidentiality NoticeAt the Knoxville Family Justice Center, you have the following rights about your personal information and privacy: Privacy of Information: We will keep your personal information private as much as the law allows. Your Choice: You decide what information to share with us. We won’t deny you services if you choose not to share some details. No Sharing Without Permission: We will not share your personal information, such as your name or address, with anyone or any agency unless you permit us to. Required Reports by Law: By law, we must report things like: Threats to harm yourself or others Elder abuse or abuse of adults at risk We’ll let you know if we need to make a report and what information will be shared. Funding Information: We share general information (like the age or income ranges of people who use our services) with agencies that fund us. However, we will only share information identifying you if you give us written permission. Referrals to Other Help: You can choose to get help from other agencies we work with, such as: Nonprofit Agency YWCA McNabb Center Sexual Assault Center of East TN Legal Aid of East TN Law Enforcement/Government Agency Knoxville Police Department Knox County Sheriff’s Office District Attorney’s Office Control Over Shared Information: You decide how much of your personal information we share with partner agencies. We’ll explain their confidentiality rules and tell you exactly what will be shared. Tell us if you change your mind, and we’ll stop sharing your information.By clicking "Yes," you confirm that you have read and understand your rights.(Required) Yes FJC On-Site AgenciesAbuse Category(Required) Domestic Violence Sexual Assault Elder Abuse Child Abuse Agencies with Available ServicesChoose an Agency to Contact(Required) Knoxville Sheriff's Office Victim Advocate (incident or unsafe person in Knox County) Knoxville Police Department Victim Advocate (incident or unsafe person in City of Knoxville) YWCA Domestic Violence Advocate McNabb Domestic Violence Advocate McNabb Sexual Assault Advocate I Need Help WithSelect Area(s) of Need(Required) Legal Assistance Safety Planning and Support Housing and Shelter Counseling and Support Services Education and Resources Referrals for Additional Services Legal Assistance - Select Needed Service(s)(Required) File A Police Report File A Warrant Order of Protection Legal Representation for OP Safety Planning and Support - Select Needed Service(s)(Required) Safety Planning Danger Assessment Strangulation/Choking Impact Being Intimidated by Abuser Housing and Shelter - Select Needed Service(s)(Required) Needing Safe Place to Stay Needing Safe Place for Pets Counseling and Support Services - Select Needed Service(s)(Required) Counseling for Myself Counseling for My Child(ren) Support Groups Education and Resources - Select Needed Service(s)(Required) Victims Compensation Application Education/Information Referrals for Additional Services - Select Needed Service(s)(Required) Help with Transportation Child Care (Vouchers) Sexual Assault Services Child Support & Custody Clothing Educational Assistance Food General Medical Care Employment Housing Job Training Public Assistance Military Resources Limited Release of Information I authorize KFJC to share limited information with selected partner agencies to assist in providing services. I understand I can revoke this consent at any time by notifying KFJC in writing.Signature(Required)Date(Required) MM slash DD slash YYYY I am completing this form at:(Required)Select OneKnoxville Family Justice CenterHomeWorkOther LocationThis field is hidden when viewing the formNotesPlease add any notes here. . CommentsThis field is for validation purposes and should be left unchanged.
