INTAKE & REFERAL FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *EmailHow old are You?Date of BirthSocial Security NumberAre you still in a relationship with the person you assaulted?YesNo Have you ever thought of hurting or killing yourself?YesNoIf so, when?How do you describe your ethnic background?White (non Hispanic)BlackHispanicAmerican Indian, Alaskan NativeAsian Pacific IslanderOtherWhat was the level of education completed? (In USA)Less than high school (0-8 years)Some high school (9-12th but did not complete the 12th grade)High school graduate or GEDAttended a vocational, trade, or business school after high schoolCollege less than 2 yearsCollege Associates degreeCollege two years or more, no degreeCollege Bachelor's degreeCollege post graduate classes with no degreeGraduate or professional school: MA, MS, PhD, EdD, PsyD, JDWhat is your annual household income (this question is for statistical purposes and your response may change the price you pay for the program)? Must provide financial proof (4 consecutive pay stubs or previous year tax records).$ 5,000 or less$ 5,001 $ 9,999$10,000-$14,999$15,000 $24,999$25,000-$34,999$35,000 - $44,999$50,000+ was or ..... How long have you been married or in an intimate relationship? You have children?YesNoIf yes tell us about them:Child's Name & Age If yes what are you takingAre you taking any medication?YesNoDoes your child live with you?Do you have any significant health, drug, alcohol or psychiatric issues/concerns?YesNoPlease ExplainWas there Alcohal and Drug Abuse in the home While you were growing up?YesNoWhat is the one word that best describes youAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHave paid through ..... $CASHAPP (or) ZELLEZELLE$CASHAPPSend me Payment through ZELLEGeorge Steed 281.507.5444Upload your payment ScreenshotSend me Payment through $CASHAPP$MrGeorgeSteed3Upload your payment Screenshot Submit
