Advocacy - Information about Person Served | |||
| Date of Initial Contact Select Date (today) | Participant Code | Staff/Worker | |
Demographics of Person Served (this may not be the victim) | |||||||||
| Gender: | Race: (check all that apply): |
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Approximate Age: | ||||||
| Locality of Residency (City, County, College/University, Military Base, or Out-of State): | Show all localities | ||||||||
| Does the person identify as a person with a disability? | Yes No N/A | ||||||||
| If yes, is the disability a result of the domestic and/or sexual violence? | Yes No N/A | ||||||||
| Does the person identify as a person of Hispanic/Latino(a) Ethnicity | Yes No N/A | ||||||||
| Is any household member a dependent of, active, or retired military? | Yes No N/A | ||||||||
| Has the person used your program services before? | Yes No N/A | ||||||||
| Is the person eligible for TANF (Temporary Assistance to Needy Families)? | Yes No N/A | ||||||||
| Does the person report concerns for children who have been exposed to the violence? | Yes No N/A | ||||||||
| How did the person learn about your program services? | |||||||||
| History of Violence Experienced | ||
| Please check all that apply. Please base all responses on the violence experienced by the person being served (this my not be the victim). | ||
| Adult-Domestic Violence | Adult-Sexual Violence | Other |
| Victim of Domestic Violence | Victim of Sexual Violence | Violence |
| Victim of Domestic Violence as a Child | Victim of Sexual Violence as a Child | Stalking (Non SV/DV Related) |
| Family/Friend of Victim | Family/Friend of Victim | |
| Parent/Caretaker of a Victim | Parent/Caretaker of a Victim | |
| Child/Youth-Domestic Violence | Child/Youth-Sexual Violence | |
| Victim of Domestic Violence/Abuse | Victim of Sexual Violence/Abuse | |
| Victim Exposed to Domestic Violence | Victim Exposed to Sexual Violence | |
| Family/Friend of Victim | Family/Friend of Victim | |
| Parent/Caretaker of Victim | Parent/Caretaker of Victim | |
| Other Reason for Advocacy-Non SV/DV Related | ||
| Homelessness | ||
| Other Service Oriented | ||
| Date of Contact Select Date (today) | Participant Code | Staff/Worker |
| Have any of the demographics for the person changed? If so, remember to update Information Sheet. | |||||||||||||
| Description of Person Receiving Services: | Type of Sexual Violence Experienced: | ||||||||||||
| Please check only one | Please check only one | ||||||||||||
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| Perpetrator Information on Presenting Sexual Violence Experience: | |||||||||||||
| Please complete based on the primary presenting sexual violence incident. | |||||||||||||
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Race: (check all that apply): |
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| Is the perpetrator a person of Hispanic/Latino(a) Ethnicity? | Yes No N/A | ||||||||||||
| Relationship to the Victim: | |||||||||||||
| Location of the Presenting Sexual Violence Experience: | |||||||||||||
| Legal Action Related to the Presenting Sexual Violence Experience: | |||
| Please complete based on any legal action that has already occurred related to the presenting incident. | |||
| 1) Was the incident reported to the police? | Yes No N/A | ||
| 2) Was the victim denied access to PERK when requested? | Yes No N/A | ||
| 3) Was the victim polygraphed or asked to submit to a polygraph? | Yes No N/A | ||
| 4) Has a protective order been issued? | Yes No N/A | ||
| If no, was it requested, but denied? | Yes No N/A | ||
| If yes, Protective Order issued was: | EPO PPO PO | ||
| 5) Have charges been filed against the perpetrator? | Yes No N/A | ||
| If yes, charge was: | Misdemeanor Felony Both | ||
| Impact of the Presenting Sexual Violence | ||
| Concerns expressed by the person receiving services: | ||
| 1.) Ability to meet basic financial needs | ||
| 2.) Access to affordable and safe housing (eviction concerns, ability to meet essential housing expenses,--rent, utilities, etc | ||
| 3.) Awareness & access to community resources (how to continue to get help) | ||
| 4.) Family stability (fear of abandonment, family separation, etc.) | ||
| 5.) Impact of the violence on the children | ||
| 6.) Impact on non-offending partner | ||
| 7.) Impact of violence on non-offending parent/guardian | ||
| 8.) Mental/Emotional health (fear, anxiety, sadness, shame, difficulties at work, school performance, etc.) | ||
| 9.) Immigration (fear that self or others will be deported, documentation status) | ||
| 10.) Legal issues | ||
| 11.) Physical well-being (activity level, stress level, health issues/symptoms, sleep and eating patterns) | ||
| 12.) Safety (feeling unsafe, threatened, or in danger of physical or emotional harm) | ||
| 13.) Sexual well-being | ||
| 14.) Spiritual well-being | ||
| 15.) Support/relationships (trust, relationships w/in the community, family & friends) | ||
| What are the primary concerns for the victim on initial contact? | ||
| Please select up to three numbers from the list above. | ||
| 1.) | ||
| 2.) | ||
| 3.) | ||
| Self-Advocacy for Presenting Sexual Violence | ||
| Please indicate what support systems/services the person receiving services as accessed and whether or not it was hlpfl in responding to the violence. | ||
| Was It Helpful? | ||
| Counseling/Support Group Services | Yes No | |
| Going to Court | Yes No | |
| Faith Community (e.g. congregation member, clergy) | Yes No | |
| Family & Friends | Yes No | |
| Hospital, Doctor, or Health Clinic | Yes No | |
| Filing a Police Report | Yes No | |
| Self-Defense | Yes No | |
| Protection Orders | Yes No | |
| Relocation | Yes No | |
| Social Worker/Social Services (e.g. child or adult protective services) | Yes No | |
| Another Sexual or Domestic Violence Agency | Yes No | |
| Neighbor or Community Member | Yes No | |
| Risk Assessment/Safety Planning | |||
| Please answer the following risk assessment questions. | |||
| If perpetrator is a former partner/spouse, is the separation recent? | Yes No N/A | ||
| Has the perpetrator stalked the victim or the victim's parent? | Yes No N/A | ||
| Has the perpetrator used a weapon, or an object as a weapon against the victim or victim's parent? | Yes No N/A | ||
| Has the perpetrator threatened to use or used a firearm against the victim or victim's parent? | Yes No N/A | ||
| Has the perpetrator made threats of suicide and/or homicide? | Yes No N/A | ||
| Has the perpetrator blocked or obstructed the victim's or victim's parent's breathing? | Yes No N/A | ||
| Has the perpetrator hurt or threatened the victim's or victim's parent's children? | Yes No N/A | ||
| Has the perpetrator hurt or threatened to harm a person (other than children) or pet the victim cares for? | Yes No N/A | ||
| Has the perpetrator destroyed or threatened to destroy the victim's or victim's parent's property? | Yes No N/A | ||
| If dependent upon the perpetrator, has the perpetrator kept the victim or victim's parent from getting help with a personal need, such as eating, bathing, toileting, or access to medications? | Yes No N/A | ||
| Is the victim or victim's parent pregnant? | Yes No N/A | ||
| As a result of the violence, did the victim or victim's parent (Please complete for ALL victims): | |||
| Sustain physical injuries requiring emergency medical attention? | Yes No N/A | ||
| Miss time from work or school? | Yes No N/A | ||
| Experience a loss of income and/or financial security? | Yes No N/A | ||
| Become homeless? | Yes No N/A | ||
| Have to relocate? | Yes No N/A | ||
| Consider Suicide | Yes No N/A | ||
| If the victim is a child/youth (please read carefully, a 'yes' indicates the child is at risk): | |||
| 1) Is the child/youth without a protective adult in the house? | Yes No N/A | ||
| 2) Is the child/youth unable to identify other trusted adults? | Yes No N/A | ||
| If the answer to both questions is "yes", child was assisted by: | |||
| Helping to identify a trusted adult | |||
| Providing telephone numbers to call in an emergency | |||
| Providing information to parent to give to child | |||
| No opportunity to address with child | |||
| Please complete a new sheet for each new presenting experience | |||
| Date of Contact Select Date (today) | Participant Code | Staff/Worker | |
| Description of Person Receiving Services: | Type of Domestic Violence Experienced: | ||||||||||||
| Please check only one | Please check only one | ||||||||||||
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| Perpetrator Information on Presenting Domestic Violence Experience: | |||||||||||||
| Please complete based on the primary presenting domestic violence incident. | |||||||||||||
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Race: (check all that apply): |
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| Is the perpetrator a person of Hispanic/Latino(a) Ethnicity? | Yes No N/A | ||||||||||||
| Relationship to the Victim: | |||||||||||||
| Location of the Presenting Domestic Violence Experience: | |||||||||||||
| Legal Action Related to the Presenting Domestic Violence Experience: | |||
| Please complete based on any legal action that has already occurred related to the presenting incident. | |||
| 1) Was the incident reported to the police? | Yes No N/A | ||
| 2) Did the police request an Emergency Protective Order? | Yes No N/A | ||
| 3) Has a protective order been issued? | Yes No N/A | ||
| If no, was it requested, but denied? | Yes No N/A | ||
| If yes, Protective Order issued was: | EPO PPO PO | ||
| 4) Have charges been filed against the perpetrator? | Yes No N/A | ||
| If yes, charge was: | Misdemeanor Felony Both | ||
| 5) Has the victim (if a child, the victim's parent) or perpetrator petitioned for custody/visitation/support? | Yes No N/A | ||
| Impact of the Presenting Domestic Violence | ||
| Concerns expressed by the person receiving services: | ||
| 1.) Ability to meet basic financial needs | ||
| 2.) Access to affordable and safe housing (eviction concerns, ability to meet essential housing expenses,--rent, utilities, etc | ||
| 3.) Awareness & access to community resources (how to continue to get help) | ||
| 4.) Family stability (fear of abandonment, family separation, etc.) | ||
| 5.) Impact of the violence on the children | ||
| 6.) Impact on non-offending partner | ||
| 7.) Impact of violence on non-offending parent/guardian | ||
| 8.) Mental/Emotional health (fear, anxiety, sadness, shame, difficulties at work, school performance, etc.) | ||
| 9.) Immigration (fear that self or others will be deported, documentation status) | ||
| 10.) Legal issues | ||
| 11.) Physical well-being (activity level, stress level, health issues/symptoms, sleep and eating patterns) | ||
| 12.) Safety (feeling unsafe, threatened, or in danger of physical or emotional harm) | ||
| 13.) Sexual well-being | ||
| 14.) Spiritual well-being | ||
| 15.) Support/relationships (trust, relationships w/in the community, family & friends) | ||
| What are the primary concerns for the victim on initial contact? | ||
| Please select up to three numbers from the list above. | ||
| 1.) | ||
| 2.) | ||
| 3.) | ||
| Self-Advocacy for Presenting Domestic Violence | ||
| Please indicate what support systems/services the person receiving services has accessed and whether or not it was hlpfl in responding to the violence. | ||
| Was It Helpful? | ||
| Counseling/Support Group Services | Yes No | |
| Going to Court | Yes No | |
| Faith Community (e.g. congregation member, clergy) | Yes No | |
| Family & Friends | Yes No | |
| Hospital, Doctor, or Health Clinic | Yes No | |
| Filing a Police Report | Yes No | |
| Self-Defense | Yes No | |
| Protection Orders | Yes No | |
| Relocation | Yes No | |
| Social Worker/Social Services (e.g. child or adult protective services) | Yes No | |
| Another Sexual or Domestic Violence Agency | Yes No | |
| Neighbor or Community Member | Yes No | |
| Risk Assessment/Safety Planning | |||
| Please answer the following risk assessment questions. | |||
| If perpetrator is a former partner/spouse, is the separation recent? | Yes No N/A | ||
| Has the perpetrator stalked the victim or the victim's parent? | Yes No N/A | ||
| Has the perpetrator used a weapon, or an object as a weapon against the victim or victim's parent? | Yes No N/A | ||
| Has the perpetrator threatened to use or used a firearm against the victim or victim's parent? | Yes No N/A | ||
| Has the perpetrator made threats of suicide and/or homicide? | Yes No N/A | ||
| Has the perpetrator blocked or obstructed the victim's or victim's parent's breathing? | Yes No N/A | ||
| Has the perpetrator hurt or threatened the victim's or victim's parent's children? | Yes No N/A | ||
| Has the perpetrator hurt or threatened to harm a person (other than children) or pet the victim cares for? | Yes No N/A | ||
| Has the perpetrator destroyed or threatened to destroy the victim's or victim's parent's property? | Yes No N/A | ||
| If dependent upon the perpetrator, has the perpetrator kept the victim or victim's parent from getting help with a personal need, such as eating, bathing, toileting, or access to medications? | Yes No N/A | ||
| Is the victim or victim's parent pregnant? | Yes No N/A | ||
| As a result of the violence, did the victim or victim's parent (Please complete for ALL victims): | |||
| Sustain physical injuries requiring emergency medical attention? | Yes No N/A | ||
| Miss time from work or school? | Yes No N/A | ||
| Experience a loss of income and/or financial security? | Yes No N/A | ||
| Become homeless? | Yes No N/A | ||
| Have to relocate? | Yes No N/A | ||
| Consider Suicide | Yes No N/A | ||
| If the victim is a child/youth (please read carefully, a 'yes' indicates the child is at risk): | |||
| 1) Is the child/youth without a protective adult in the house? | Yes No N/A | ||
| 2) Is the child/youth unable to identify other trusted adults? | Yes No N/A | ||
| If the answer to both questions is "yes", child was assisted by: | |||
| Helping to identify a trusted adult | |||
| Providing telephone numbers to call in an emergency | |||
| Providing information to parent to give to child | |||
| No opportunity to address with child | |||
| Date of Service Select Date (today) | Participant Code | Staff/Worker | |
| Daily Record Entry Weekly Record Entry | |||
Has a new incident been reported? If so, remember to complete a new Presenting Sexual and/or Domestic Violence sheet. |
Advocacy Services & Referrals |
| Please fill out this section for each date of service provided to the victim. To be completed for shelter and non-shelter residents. |
| SV DV Other | |
| Academic Support/Services | |
| Accommodation Services - Disability | |
| Accommodation Services - English not Primary Language | |
| Accommodation Services - Other | |
| Accompaniment Services - Medical | |
| Accompaniment Services - Other | |
| Child Care | |
| Counseling/Support | |
| Crisis Intervention | |
| Education Dynamics of SV/DV | |
| Emergency Housing/Shelter | |
| Employment Related Services | |
| Financial Assistance | |
| Group Agency Sponsored | |
| Hotline Services | |
| Housing Services | |
| Information and Referral | |
| Safety Planning Victim | |
| Safety Planning Parent or Guardian | |
| Safety Planning Other | |
| Services to Address Basic Needs | |
| Skill/Personal Development | |
| System's Advocacy | |
| Therapy (licensed) | |
| Transportation | |
| Therapeutic Activities - Other |
| Shelter/Emergency Housing Services | ||
| Did the victim request shelter/emergency housing services? | Yes No N/A | |
| If yes, was shelter/emergency housing provided/arranged/offered? | Yes No N/A | |
| If shelter/emergency housing was NOT provided: | ||
| Reason: | Shelter Full Outside Area Doesn't Meet Criteria | |
| Did you arrange alternative emergency housing? | Yes No N/A | |
| Legal Advocacy Services: (Check all that apply) | ||
| SV DV Other | ||
| Accompaniment Services-Criminal | ||
| Accompaniment Services-Civil | ||
| Accompaniment Services-Forensic Exam | ||
| Assistance Filing For Victim's Compensation | ||
| Criminal Justice Information/Support | ||
| Assistance Filing for EPO/PPO/PO | ||
| Petition Awarded | ||
| Petition Denied | ||
| Assistance Filing for Custody/Visitation/Support | ||
| Petition Awarded | ||
| Petition Denied | ||
| Legal Representation (staff attorney) | ||
| Referrals Provided: | ||
| SV DV Other | ||
| College/University Services | ||
| Education Services | ||
| Disability Services | ||
| Employment Services | ||
| Faith Community Services | ||
| Health Care/Medical Services | ||
| Homelessness Services | ||
| Immigration Services | ||
| Legal Services | ||
| Mental Health Services | ||
| Military Services | ||
| Other Community Services | ||
| Other Services within your Program | ||
| Other Sexual/Domestic Violence Agency | ||
| Social Services | ||
| Number of Advocacy Contacts Made on Behalf of Person Receiving Services: | Number of Hours of Service Provided: |
| Participant Code | Staff/Worker |
Shelter/Emergency Housing Services: | ||
| Date of Shelter Entrance: Select Date (today) | ||
| Reason Shelter is Needed: (Check all that apply) | ||
| DV Imminent Danger | ||
| SV Imminent Danger | ||
| DV Homelessness | ||
| SV Homelessness | ||
| Homelessness | ||
| Type of Shelter Provided: (Check only one) | ||
| Program's Shelter Hotel Other | ||
| Legal Actions During Shelter Residence: (Check all that apply) | |||||
| Protective Order | Petitioned | Awarded | Denied | ||
| Criminal Charges | Charged | Adjudicated | |||
| Custody | Petitioned | Awarded | |||
| Visitation/Support | Petitioned | Awarded | |||
| Child Abuse/Neglect Proceedings | Reported | Investigated | Charged | Adjudicated | |
| Date of Shelter Exit: Select Date (today) | ||
| Victim Exited To: (Check only one) | ||
| Entered Another Shelter | Home, abuser no longer present | Home, abuser present |
| Left Area | Residence of friend/relative | Self-supported Housing |
| Transitional Housing | Other | Unknown |
| Transitional Housing Services: | ||
| Please complete this form for each transitional housing stay. | ||
| Date of Entrance: Select Date (today) | Date of Exit: Select Date (today) | |