Endeavors Safe Services Intake

Client Intake Form

Step 1 of 10

Name (First and Last)

Please enter your legal name.

Preferred Name

Preferred Pronouns

He/Him She/Her They/Them Other

What County do you reside in?

Have you been a victim or witness of a crime?

Adult Physical Assault (Including Aggravated and Simple Assault) Adult Sexual Assault Adult sexually Abused/Assaulted as Children Arson Bullying (Verbal, Cyber, or Physical) Burglary Child Physical Abuse or Neglect Child Sexual Abuse/Assault Child Pornography Domestic and/or Family Violence DUI/DWI Incidents Elder Abuse or Neglect Hate Crime: Racial/Religious/Gender/Sexual Orientation, etc. Human Trafficking: Labor Human Trafficking: Sex Identity Theft/Fraud/Financial Crime Kidnapping (non-custodial) Kidnapping (Custodial) Mass Violence (domestic/international) Other Vehicular Victimization (e.g., Hit and Run) Robbery Stalking/Harassment Survivor of Homicide Teen Dating Victimization Terrorism (Domestic/International)

Please specify the type of Hate Crime:

Race/Ethnicity/Ancestry Religion Sexual Orientation Disability Gender Gender Identity Other

8. Which of our services are you interested in?

Professional Therapy/Counseling Community/Mental Health Resources Transportation Court Accompaniment

Do you use tobacco products?

Yes No

Are you interested in Nicotine replacement therapy?

Yes – I’m ready to start Yes, but I have a lot going on right now; please ask me in 3 months No

Which of the following apply to you?

I identify as part of the LGBTQIA+ community I am struggling with a mental health barrier I do not feel safe where I live I am currently unhoused I am living with a disability I am an Immigrant/Refugee/Asylum Seeker I have limited English proficiency I am a veteran

Are you in any of our other endeavors programs?

Yes No

Which program?

This information will help us work together to provide you the best care. This will not affect your eligibility for the program.

Phone Number

Can we leave a message at this number?

Yes No

Preferred method of contact

Email Phone

Zip Code

Date of Birth

Will you need transportation to and from Endeavors for appointments?

Yes No

Transportation Service Terms

Available Monday–Friday, 8 AM–3 PM only. Bexar County appointments only. VOCA services only.

Request rides 24 hours in advance. Monday appointments must be requested by Friday.

Reply to Uber Health texts when ready for pickup and for return trip.

Canceling after booking counts as a no‑show. Three no‑shows in six months results in suspension.

Same‑day service only for mental health crisis as determined by a clinician.

Accept Terms Decline Terms

Gender Identity

Male Female Non-binary Prefer not to say Other

Race/Ethnicity

American Indian/Alaska Native Asian Black/African American Hispanic or Latino Native Hawaiian and Other Pacific White Non-Latino/Caucasian Some other Race Multiple Races Unknown Decline to Answer

Do you need a translator for a language other than English?

Yes No

What is your military connection? (Select all that apply)

I am currently serving I am a veteran I am a military dependent/family member No military connection

If yes, what branch(s)?

Air Force Army Coast Guard Marine Corps Navy Space Force National Guard Reserves

Year of separation (if applicable)

How did you hear about us?

Friend/Family Social Media Healthcare Provider Court Other

Any additional comments you would like to add?

VOCA Participant Agreement

Referrals and Follow‑Up: I understand VOCA provides referrals but not direct financial assistance, and I am responsible for follow‑up within 5 business days. Role of Staff: Endeavors staff cannot complete applications or attend appointments on my behalf, but may join conference calls and provide court accompaniment. Maintaining Contact: Failure to maintain contact for 60 consecutive days will result in termination of services. Accurate Information: Providing false information or being verbally abusive to staff will result in dismissal from the program.

All boxes must be checked to proceed.

Application Submitted

Thank you for applying for our Endeavors Safe Services Program.

You will receive a follow up contact within 48 hours. Please be checking your email as that is the form of initial contact. Please be looking out for an email from us!

During holidays, please allow more time to accommodate for office closures.

If you have any questions, or if you have not heard from us in over 48 hours, please contact (call or text) our office:

Masha

Endeavors Safe Services

(210) 866-3860 ess@endeavors.org

Submitting Application

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Corporate headquarters

6363 De Zavala Road

San Antonio, Texas 78249

(833) 828-6439