SMART CHOICES™ COURT DIVERSION PROGRAMS

3909 S Maryland Pkwy, Suite 405, Las Vegas, Nevada 89119

Office: (702) 308-7414 | Fax: (702) 749-5882 | Program Director: Kelly Gafford

Domestic Violence Program — Intake Packet

Step 1 of 7: Client Info

Section 1: Client Enrollment & Intake

First Name *

Last Name *

Address

City / State / Zip

Date of Birth *

Age / Sex

Primary Phone *

Cell Phone

Email Address *

SSN

Case Number

Marital Status

Race / Ethnicity (For Statistical Purposes Only — Check One) *

Emergency Name

Relationship / Phone

Are you a Military Veteran? *

Are you living with a diagnosed disability? *

Have you ever been convicted of a violent or sexual crime? *

Are you currently taking medications of any kind? (If yes, list below) *

Drug of Choice

Number of Overdoses

Alcohol

Marijuana

Cocaine / Amphetamines

Heroin / Opiates