Intake Form

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This field is for validation purposes and should be left unchanged.

Are you currently living in the state of Colorado?

Are you a victim of one of the following crimes: domestic violence, domestic abuse, sexual assault, human trafficking, family violence, caretaker abuse?

We're Sorry — You May Not Be Eligible for Services

Based on your responses, it looks like you may not meet the eligibility criteria for services provided by The Initiative at this time. We know reaching out for support takes courage, and we want to make sure you’re connected to the right resources. If you have questions about your eligibility or would like help finding alternative services, please feel free to call or text our hotline at (303) 839-5510 or email us at info@theinitiativeco.org

You can also dial 2-1-1 or visit 211colorado.org to find other services and resources near you.

If you believe you are eligible for services, please reach out to us by calling 303-839-5510 or email us at info@theinitiativeco.org

Name

First Last

Pronouns

Other

Safe Phone Number:

Safe Email Address:

Enter Email Confirm Email

Language:

If Other, please list your primary language

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(depreciated) Language:

Birthday:(Required)

MM slash DD slash YYYY

Are you completing this form for yourself or on behalf of someone else?

What is your relationship to the person you're completing this form on behalf of?

Is there anything about your culture or disabilities that would be helpful for us to know about?:

if it is safe to call you?

Check if it is safe to leave a message?

Check if it is safe to email you?

Are you currently being stalked?

How do you want us to reach out to you?

Phone Call

Text

Mail

Demographic Information - We ask these questions so that we can suggest options or programs that are appropriate for you. We also use this information to track trends within our organization. For example, one of our funders might ask us what age range we serve, or what percentage of our clients are women.

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(depreciated) City, County where you live:

City, County where you live:(Required)

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(depreciated) City, County of abuse:

City, County of abuse:

Do you live in a rural area?:

Yes

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are you currently experiencing homelessness?

Yes

Are you currently staying in a Safehouse or Shelter? Which one?:

When is your exit date?:

MM slash DD slash YYYY

What is your relationship status?

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(depreciated)Gender Identity (select any/all that apply):

Gender Identity

Write in gender identity if not listed above:

Race:

White

Black or African American

Hispanic or Latino

Asian

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Middle Eastern or North African

Other

Prefer not to say

This field is hidden when viewing the form

Racenew:

Hispanic/Latino:

Yes

Number of Children (Under 18):

Please enter a number from 0 to 20.

Where are your children?:

Source of Income:

Full Time Employment

Part Time Employment

SSI

SSDI

AND

TANF

SNAP (Food Stamps)

Child Support

Other

None

Medical Insurance:

Medicaid

Medicare A

Medicare B

CICP

Supplemental

Private

Do you rely on your partner's income or insurance?:

Disabilities - The Initiative is a disability centered organization. People with disabilities experience higher rates of abuse, and there aren’t very many services out there that are set up to help. We ask about your disabilities so that we can begin to understand your unique experience, do disability specific safety planning, provide disability specific resources, and track the types of disabilities that our clients have. Anybody who has experienced abuse can seek services from us, even if you do not have a disability, or if you do not identify as disabled.

What types of disabilities do you have (if any)? Select all that apply:

Physical

Cognitive

Mental Health

Health Conditions

Sensory

Developmental

Other

If you want to, please list specific disabilities here:

Abuse - This section asks questions about the abuse. You can tell us as much or as little as you want to.

Relationship to the Person who Harmed You:(Required)

Spouse

Ex Spouse

Dating

Child In Common

Family Member

Parent

Child

Caretaker

Stranger

Acquaintance

Other

Something else?:

Are you still living with the abuser?

Type of Abuse:(Required)

Intimate Partner Violence (Domestic Violence)

Family Violence

Sexual Assault

Stalking

Something else?:

Date of Most Recent Incident:(Required)

MM slash DD slash YYYY

Was an arrest made?

If so, what County was the arrest made in?

Is there anything about the incident that would be helpful for us to know?:

Do you have a Protection Order (Restraining Order):

Yes

Additional Statistical Questions - These questions are used for research. You do not need to answer them if you don’t want to. If you are a survivor of childhood abuse, we encourage you to reach out to WINGS foundation for support: https://www.wingsfound.org/

Were any of your disabilities caused by the abuse?:

Yes

Have you ever been declined shelter due to your disabilities?:

Yes

Have you asked for an accomodation at a shelter and recieved it?:

Yes

Do you feel safe calling the police in an emergency?:

Yes

Did you experience child abuse when you were a kid?:

Yes

If yes, was it sexual abuse?:

Yes

Needs

Describe what prompted you to reach out to us today:(Required)

Do you have any personal safety concerns? When we contact you we can make a safety plan around your concerns. You can also find a safety planning checklist at the bottom of this page to help get you started. :

Do you have any safety concerns for others?

What are the biggest barriers you are facing to reaching safety? You can use this space to describe things you are wanting help with:

Is there anything else that you're worried about?:

How did you hear about us?(Required)

I can cope with whatever challenges come at me as I work to keep safe.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

I have to give up too much to keep safe.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

I know what to do in response to threats to my safety.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

I have a good idea about what kinds of support for safety that I can get from people in my community (friends, family, neighbors, people in my faith community, etc.).(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

I know what my next steps are on the path to keeping safe.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

Working to keep safe creates (or will create) new problems for me.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

When something doesn’t work to keep safe, I can try something else.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

I feel comfortable asking for help to keep safe.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

When I think about keeping safe, I have a clear sense of my goals for the next few years.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

Working to keep safe creates (or will create) new problems for people I care about.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

I feel confident in the decisions I make to keep safe.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

I have a good idea about what kinds of support for safety I can get from community programs and services.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

Community programs and services provide support I need to keep safe.(Required)

Never True

Sometimes True

Half the Time True

Mostly True

Always True

Safety Alert

We are currently on a waitlist

Confidentiality

Before you begin

Colorado residents only

We're Sorry — You May Not Be Eligible for Services