VAdata

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

Advocacy - Information about Person Served
Date of Initial Contact Select Date (today)		Participant Code	Staff/Worker

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

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

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

VAdata

Advocacy - Information about Person Served

Demographics of Person Served (this may not be the victim)

Has a new incident been reported? If so, remember to complete a new Presenting Sexual and/or Domestic Violence sheet.

Advocacy Services & Referrals

Shelter/Emergency Housing Services:


Date of Contact Select Date (today)		Participant Code	Staff/Worker

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


Please complete a new sheet for each new presenting experience
Date of Contact Select Date (today)	Participant Code	Staff/Worker


Date of Service Select Date (today)	Participant Code	Staff/Worker
Daily Record Entry Weekly Record Entry

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

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)