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.

The Knoxville Family Justice Center serves clients in Knox County, Tennessee. If you are not a resident of Tennessee, please contact the National Domestic Violence Hotline at 1-800-799-7233 for assistance.

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1. Victim Information

Personal Information

Name(Required)

First Last

I am completing this form at:(Required)

New or Returning Client(Required)

Agency/Agencies You Have Worked With Before(Required)

YWCA

McNabb Center

Sexual Assault Center of East TN

Legal Aid of East TN

Knoxville Police Department

Knox County Sheriff’s Office

District Attorney’s Office

Name of Person You Worked With

FJC On-Site Agencies

Abuse Category(Required)

Domestic Violence

Sexual Assault

Elder Abuse

Child Abuse

Safety Concerns

Are there firearms in the home?(Required)

Are the firearms locked away?(Required)

Has the unsafe person ever choked you or made it hard for you to breathe?(Required)

At the time of the incident, was anyone using alcohol or drugs?(Required)

Agencies with Available Services

Choose an Agency to Contact(Required)

YWCA Domestic Violence Advocate

Choose an Agency to Contact(Required)

YWCA Domestic Violence Advocate

Choose an Agency to Contact(Required)

YWCA Domestic Violence Advocate

Choose 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)

McNabb Domestic Violence Advocate

McNabb Sexual Assault Advocate

YWCA Domestic Violence Advocate

I Need Help With

Select Area(s) of Need(Required)

Legal Assistance

Safety Planning and Support

Housing and Shelter

Counseling and Support Services

Education and Resources

Gennisi Charitable Birth Services

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

Gennisi Charitable Birth Services - Select Needed Service(s)(Required)

Pregnancy, Birth, and Postpartum Support

Mommy Mentor

Lactation Support

Meal Prep/Nutritional Support

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 Understand:
Sharing my information is my choice. I will share only the information listed below. If I want to share more details later, I must sign another form. Sharing my information could show my location or confirm that I get help from The Knoxville Family Justice Center.Once my information is shared, I and the Knoxville Family Justice Center cannot control who sees it. The person or agency who receives it might have to share it by law.

Information Sharing Methods (check all that apply):

In-person

Mail

Email (I understand email is not private, and others could see it)

Information to Share:

Victim name and contact information

Unsafe person information

Service requests

Supporting documents

Police reports

Reasons for Sharing Information:

Victim Advocacy

Order of Protection

Police Reports

Legal Assistance

Social Services

Medical/Behavioral Health Supports

This form expires one year from today. I understand I can cancel this permission anytime. To cancel this permission, please email info@fjcknoxville.org.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Rights and Confidentiality Notice

At 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.

Criminal Injuries Compensation Fund
The Criminal Injuries Compensation Fund helps innocent victims of violent crimes in Tennessee by covering some of their costs. If someone is hurt in a crime, they may get help paying for medical bills, lost wages, or other expenses caused by the crime. If the victim passes away, their family may also qualify for financial help.

The Tennessee Department of Treasury runs this program to support people in need. If you think you might be eligible, talk to your advocate for more information and help with the application.

By clicking "Yes," you confirm that you have read and understand your rights.(Required)

Yes

Address(Required)

Street Address City State ZIP Code

Race(Required)

Gender(Required)

What kind of relationship do you have with the unsafe person?(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Safe Phone(Required)

Safe Email(Required)

How do you want us to contact you?(Required)

Primary Language(Required)

What is the best time to contact you?(Required)

Interpreter Needed(Required)

Veteran(Required)

Age Range(Required)

Annual Household Income(Required)

Are you deaf or hard of hearing?(Required)

What is your current housing situation?(Required)

Do you identify as an immigrant, refugee, or asylum seeker?(Required)

Do you identify as LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, or other)?(Required)

Do you have a disability? (Select all that apply)(Required)

Cognitive disability (e.g., learning disability, intellectual disability)

Physical disability (e.g., mobility impairments, chronic illness)

Mental health disability (e.g., anxiety, depression, PTSD)

Other (please specify)

Prefer not to answer

Please elaborate on the disability.(Required)

Emergency Contact

Emergency Contact Name(Required)

First Last

Relationship(Required)

Phone(Required)

2. Children Under 18

Click the Plus Icon to Add Additional Children

Name

Date of Birth

Resides With?

Gender?

School/Daycare

3. Unsafe Person Information: Who are you here to talk about?

Click the Plus Icon to Add Additional Unsafe People(Required)

Name

Race

Gender

Phone

Date of Birth

Additional Details

Unsafe Person/People Might Flee

Check to Add Details of Unsafe Person's Potential Location(s)

Click the Plus Icon to Add Additional Unsafe People

Name of Unsafe Person

Location Unsafe Person May Be At Now

Unsafe Person Might Flee To (Name, Phone)

Police 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 Addresses

Name of Unsafe Person

Street Address

City

State

Zip Code

Physical Appearance

Check to Add Physical Appearance Details for Unsafe Person/People

Click the Plus Icon to Add Additional Unsafe People

Name of Unsafe Person

Height

Weight

Eye Color

Hair Color

Facial Hair (e.g., beard, mustache, clean-shaven)

Distinguishing Marks (e.g., scars, tattoos, birthmarks, piercings)

Complexion/Skin Tone

Build/Body Type (e.g., slim, athletic, heavyset)

Employment History

Check to Add Employment History Details for Unsafe Person/People

Click the Plus Icon to Add Additional Jobs

Name of Unsafe Person

Employer Name

Supervisor Name

Car Description

Check To Add Description of the Unsafe Person/People's Car(s)

Click the Plus Icon to Add Additional Cars

Name of Unsafe Person Who Owns This Car

Make

Model

Color

Year

Tag Number

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

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Notes

Phone

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