Case Intake

Name *

First

Last

Middle Name

Preferred Name (s)

Gender Identity *

Sexual Orientation *

Phone *

Email *

Age *

Occupation *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Alternate Contact Person *

Individual-Case or Community-case(Are you the victim or reporting on behalf of someone?) *

If you’re reporting on behalf of someone, how did the case come to you? *

Subject Matter *

If You Selected Others

Description of Case (Include what, when, where, how and who *

Steps already taken Client Desire Goal(s) or outcome(s) *

Consequences of the violation ( How did this violation affect the victim mentally/physically or emotionally) *

Was there any witness when the incident took place? If yes, who? *

Withness Name *

Withness Phone number *

Withness Email *

Do you think that the acts identified above were based on your sexual orientation/ gender identity or gender expression *

Do you know anyone else who has suffered from the acts described above? (Relevant in order to identify systemic violations) *