SEXUAL VIOLENCE INTAKE FORM

World Ebony Network (WEN) is committed to supporting survivors of sexual violence with dignity, respect, and care. This Legal Referral Intake Form helps us understand your situation or that of the victim you are seeking justice for and connect you with legal resources that best match your needs (such as protection orders, workplace or school remedies, housing support, family law help, or civil legal options). You may share only what you feel comfortable sharing—there are no “right” or “wrong” answers, and you can skip any question. However, please note that the more information you provide on your intake form reduces the amount of time the attorney would spend questioning you during consultation. It would make you consultation time more meaningful.

If you are in immediate danger or need urgent medical assistance, call your local emergency number right away. Please note that submitting this form does not create an attorney–client relationship with WEN or any attorney, and WEN cannot guarantee that an attorney will accept your case; however, we will make every effort to provide an appropriate referral and follow up with you using the safest contact method you identify.

Date / Time of Application *

Date

Time

I am Completing This Intake Form For *

• Self
• Relative – Parent
• Relative – Spouse
• Relative – Child
• Relative – Sibbling

Please Select Area that Best Describes the Case You Are Seeking an Attorney for *

• Victims Right – Victim/survivor-focused legal aid: Area of need includes protection / restraining orders; Crime-victim rights advocacy (help enforcing your rights during an investigation/case) Housing, employment, public benefits Title IX / school processes Immigration options
• Civil “sexual assault/sexual abuse”: Area of need includes plaintiff’s personal injury attorney with sexual assault/abuse experience, or Civil rights attorney (in some cases, e.g., institutional misconduct, government actors)
• Family Law: Area of need includes A protective order (some states route these through family court), Divorce, custody, or child support issues connected to the abuse, a family law attorney is often the right fit. (Some survivor legal clinics also handle these issues.)
• Employment – Workplace: Area of need includes employment law attorney (sometimes “workplace harassment” or “discrimination” counsel)
• Title IX / education: Area of need includes incidents that happened at a school/college and you’re navigating a campus process, look for: A Title IX or education law attorney (or a survivor legal clinic that provides Title IX support)
• Immigration (If you’re a non-citizen survivor and immigration status/safety): Area of need includes Immigration attorney experienced with survivor-based relief can be important. (Many survivor legal aid programs also include immigration help.)

Interpreter Needed? *

• Yes
• No
• Unsure

Best Method of Communication *

• Phone
• Email
• In Person
• Video
• Any of the Above

Preferred Language *

If Voicemail Ok? *

• Yes
• No
• At Certain Times

How Urgent Is this Case? *

• Emergency
• High
• Routine

If Text Ok? *

• Yes
• No
• At Certain Times

If WEN Cannot Reach You, May We Contact an Alternative/Safe Contact? *

• Yes
• No
• At Certain Times – Provide Times to Attorney
• Each Time

CONTACT INFORMATION – Of Person Completing this Form on Behalf of Self or Someone Else

CLIENT INFORMATION – Of Person with Issue

Contact's Name *

First

Last

Client's Name *

First

Last

Contact's Email *

Client's Email *

Contact's Phone Number *

Client's Phone Number *

Contact's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Client's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Alternative/Safe Contact *

First

Last

CLIENT DEMOGRAPHIC INFORMATION

CLIENT EMPLOYMENT

Client's Age Range *

• Under 18
• 18 – 24
• 25 – 34
• 35 – 44
• 45 – 54
• 55 – 64
• Above 64

Is Client Employed? *

• Yes
• No

Client's Marital Status *

• Single (Never Married)
• Married
• Divorced
• Widowed

Client's Job Title/Description *

Race/Ethnicity *

• Hispanic
• Black or African American
• Divorced
• Asian
• Native American or Alaska Native
• White
• Middle Eastern or North African

Client's Employer's Name and Address *

Client's County of Residence? *

Client's Immigration Status? *

• Citizens
• Conditional and Permanent Residents
• Non-Immigrant Status
• Undocumented

SAFETY AND IMMEDIATE NEEDS

Safety and Immediate Needs *

• I feel safe right now
• I do not feel safe right now
• Weapons Involved or Access to Weapons
• The person who harmed me knows where I live/work/school
• I am concerned about retaliation/Stalking
• I need emergency shelter/housing
• My children or dependents might be at risk
• I need transportation or safety planning support
• Other

Tell the attorney of your safety concerns/urgent needs *

if Other, please specify *

Full Name of Accuser or Person that Hurt You *

Is This Case In Court? *

• Yes
• No

Client Relationship to Accuser/the Person that Hurt You *

Are You the: *

• Defendant
• Plantiff

LIST ALL CHARGES PENDING AGAINST CLIENT (including the Code Section if known) (copy)

Case Number *

Date of Offense *

Date

Time

Date / Time of Next Court Hearing if known *

Date

Time

Was Client Arrested? *

• Yes
• No

Is Client Out on Bail? Secured or Unsecured? *

• Yes
• No

What is the date, time, location and police department? *

Was a Protective Order Issued? *

• Yes
• No

Has Client Ever Failed to Appear in For a Court Appearance or Been Held in Contempt of Court? If So, Please Provide the Details *

Was Client on Pre-Trail Services? *

• Yes
• No

Please Provide More Details of What Lead to This Situation *

Was Client Held in Jail Overnight? *

• Yes
• No

Do You Have an Alibi? *

• Yes
• No

If Yes, How Many Nights Was Client in Jail For? *

Please Provide the Name, Address and Telephone Number of Any Eye Witnesses or Alibi Witnesses *

Is Client Currently on Probation? *

• Yes
• No

If Yes, List Name and Telephone Number of Probation/Parole Officer *

Does Client Have Any Previous Criminal Convictions? *

• Yes
• No

If Yes, List (include charge, approx date and outcome) *

Was Anyone Else Arrested With Respect to Client's Current Charge(S)? *

• Yes
• No

INFORMATION ABOUT THE ACCUSED/PERSON THAT HURT YOU

INCIDENT OVERVIEW

INCIDENT OVERVIEW – Continued

Do You Know Where the Accuser/Person that Hurt You Lives/Works? *

• Yes
• No
• Unsure

Was There Any Sexual Assault Forensic Exam (SAFE)/(SANE) Done? *

• Yes
• No
• Unsure

Do You Have Current Contact with Him/Her? *

• Yes
• No
• Limited/Avoidable

Date/Location of Exam (If Any – If None Enter 0/0/current year)) *

Did You Sustain Any Injuries? *

• Yes
• No
• Unsure

Brief Description of Incident *

Any Medical Care Received? *

• Yes
• No
• Unsure

REPORTING & CURRENT LEGAL/ADMINISTRATIVE ACTIONS

Which of These Reporting and/or Legal Actions Did You Take? *

• Reported to Police/Law Enforcement
• Did Not Report to Police
• Considered/ing Reporting
• Did/Do Not Want to Report
• A Criminal Case Is/Was Open
• A Criminal Case Was/Is Closed/Declined
• There is a No-Contact Order in Place
• There is Not a No-Contact Order in Place

Agency/Department *

Case/Report Number *

Detective/prosecutor (if known) *

Court/Case Status (if known) *

Paragraph Text *

Check All That Apply *

• Protection/Restraining order
• 1. No-contact order enforcement
• 2. Safety planning/legal options overview
• 3. Support during/police prosecutor process
• 4. Privacy protection (address confidentiality, record sealing, etc.)
• 5. Family law (custody/visitation/support)
• 6. Victim compensation

Legal Needs and Goals (What You Want Help With) *

• Protection order needed
• Protection order already filed
• Protection order granted/active
• Protection order denied/expired
• Custody/parenting issues resolved
• Child Support Unresolved
• Divorce/separation issues involved
• Immigration Issue Connected to Safety/Status

Does Client Any Mental Health Concerns? (copy) *

• Yes
• No

What Would Client Like the Lawyer to Know About Client's Mental Health Issue? *

Has Client Ever Been Institutionalized? *

• Yes
• No

If Client is Above 18, Would Client Like Us to Contact Your Family Member? *

• Yes
• No

What Age Was Client When Diagnosed of Mental Issues? *

• Under 18
• Above 18

What is Client's Family Members Contact Information? (copy) *

Additional Information About Your Case

Emergency Contact – Who May we Contact if we Cannot Get a Hold of Client?

WEN will use the information you provide to identify potential attorneys or legal service organizations. WEN is not your attorney and cannot provide legal advice. Representation begins only after you sign a separate agreement with an attorney or legal services provider. WEN will keep your information confidential to the extent allowed by law and WEN policies. There may be limits to confidentiality in situations such as imminent risk of serious harm, abuse/neglect reporting requirements, or court orders (requirements vary by location).

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Emergency Contact's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Emergency Contact Email *

Social Support System

Social support system refers to a network of people (formal or informal) – that deliberately reinforces enduring and noble principles, philosophies, and practices (See WEN mission – www.worldebonynetwork.com) that single parents can turn to for emotional, practical, economical, etc., Support. Individuals from such social support networks are willing to invest and sustain their resources i.e., time, money, etc., without feeling regrets, passing judgments, engaging in gossips, to achieve the expected goal(s).

Do You or Client Belong To Any of These Social Support Groups? *

• Cultural Association
• Fraternity & Sorority
• Church
• Peer
• Other

How Has the Support Group Assisted Client in Dealing With This Matter? *

Has the Group Been Notified or Aware of This Matter? *

• Yes
• No

Are You or Client Satisfied With the Role They've Played in Rectifying Your Situation? *

• Yes
• No

Which One of These Support Groups Have Shown Concern? *

Have Your Friends and Family Shown Their Support in This Matter? *

• Yes
• No

If Other, Specify *

Which Ones Showed Their Support (Check One or Two Boxes)? *

• Family
• Friends

Are You Satisfied With the Role They've Played in Rectifying Your Situation? *

• Yes
• No

What Role Have They Played? *

• Financial Support
• Emotional Support
• Other

Is This Case Hindering You From Carrying on Your Daily Activities? *

• Yes
• No

In What Way(s) is This Case Hindering You? *

How do You Want the Lawyer to Help You? *

What Did You or Plan to Do About It? *

Consent and Authorization to Share Information

WEN will use the information you provide to identify potential attorneys or legal service organizations. *

• I authorize WEN to share my intake information with attorneys/legal service organizations for the purpose of seeking legal consultation or representation.
• I DO NOT authorize WEN to share my information at this time (I understand this may limit referral options).

WEN is not your attorney and cannot provide legal advice. Representation begins only after you sign a separate agreement with an attorney or legal services provider. WEN will keep your information confidential to the extent allowed by law and WEN policies. There may be limits to confidentiality in situations such as imminent risk of serious harm, abuse/neglect reporting requirements, or court orders (requirements vary by location).

Signature *

Clear Signature

Culture Competence Advocacy & Mediation Program (cCAMP)

WEN’s legal referral services (LRS) WENLRS is under our Culture Competence Advocacy and Mediation Program (cCAMP), which is a culture based resource available to you to meaningfully manage your lawyer’s expectation and support your lawyer, especially with culture competence based resources to handle your case. As a potential client, you are also provided with the choice of requesting this advocacy and mediation service when completing your intake form if you feel it will help you meet your lawyer’s expectations. It will also provide you the necessary peace of you mind you need to ensure the lawyer is taking certain cultural information into consideration to manage your case as well as present before the judge. We find that this has been a tremendous help in the past, especially for clients of strong ethnic convictions. If you will like to use this service, please sign below.

I Permit WEN to Use cCAMP to Manage My's Lawyer Expectation and Support My Case *

• Yes
• No

Signature *

Clear Signature

Submit