Intake Form | Sayu’ʔ X Wey Institute

First *

Last *

Date of Birth *

Other

Have you been arrested and have pending charges for domestic abuse?

Yes

No

Are you here for an order of protection? (If yes, please see below)

Yes

No

Do you have a COMPLETE ADDRESS for the abuser whom you are filing on? (If so, please fill out address below)

Yes

No

If no, please speak with the receptionist, we must have a valid address for law enforcement to server the abuser with court papers

Street Address

City

Zip Code

State

Do you have a safe place to stay?

Yes

No

Did the police have you speak with an advocate from the Family Safety Center on the phone while taking your report?

Yes

No