Abuse Inventory Form (pdf)

Please do not complete this if the person abusing you is a stranger or someone you have never dated.
The first three pages are an abuse inventory and the fourth page is a lethality/danger assessment. It is important to understand that domestic violence is not only physical abuse. Abuse comes in many forms and can include emotional/verbal abuse, economic abuse and sexual abuse. Please be aware that domestic violence typically follows a cycle or pattern, and the severity of the abuse typically escalates over time. Several factors have been associated with increased risk of domestic violence homicides. We cannot predict what will happen in your case, but we want you to be aware of the danger in situations of abuse and for you to see the risk factors that apply to your situation.

Client Confidentiality Agreement Form (pdf)

Shasta Women's Refuge, Inc. will not tell anyone outside the agency your name or anything about you without your permission. Exceptions to this policy are suspected child abuse, elder or dependent adult abuse, serious suicidal threats or threats of violence toward someone else. Another exception would be if Women's Refuge is ordered by a court subpoena to release information about you in a legal case. We would do all we could to prevent this through the laws protecting confidentiality. Finally, because we are a private non-profit agency, auditors as well as contracted personnel, may have access to all files.

Client Intake Information Form (pdf)

This form needs to be filled out for all new clients of Shasta Women's Refuge. The information you provides allows us to better serve you.

Personalized Domestic Violence Safety Plan Form (pdf)

Create your own personalized safety plan for domestic violence situations.