Information About Person Served

Presenting Sexual Violence

Presenting Domestic Violence

Services and Referrals

Shelter Services

VFUND

VSTOP

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):
African American/Black
Asian
Caucasian
Native Hawaiian/Pacific Islander
Native American/Native Alaskan
Other/Unknown
 Approximate Age:
Locality of Residency (City, County, College/University, Military Base, or Out-of State): Show all localities
Is it a rural area? Yes No N/A
 

Other Demographics

1.) 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
2.) Does the person identify as a person of Hispanic/Latino(a) Ethnicity Yes No N/A
3.) Does the person identify as an immigrant/refugee/asylum seeker? Yes No N/A
4.) Does the person identify as a person with limited English Proficiency? Yes No N/A
5.) Is any household member a dependent of, active, or retired military? Yes No N/A
6.) Has the person used your program services before? Yes No N/A
7.) Is the person eligible for TANF (Temporary Assistance to Needy Families)? Yes No N/A
8.) Does the person report concerns for children who have been exposed to the violence? Yes No N/A
9.) Is the person enrolled in college? 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 ViolenceAdult-Sexual ViolenceOther
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
Any changes you make to this sheet will be permanent.
Please complete a new sheet for each new presenting experience.
Click to start a new sheet.
 
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 onePlease check only one
Victim
Family/Friend of Victim
Parent/Guardian of Victim
Allied Professional
None of the Above
Adult - Sexual Violence
Adult - Sexual Violence as a Child
Child/Youth - Sexual Violence/Abuse
Child/Youth - Exposed to Sexual Violence
None of the Above
Perpetrator Information on Presenting Sexual Violence Experience:
Please complete based on the primary presenting sexual violence incident.
Gender:
Approximate Age:
Race: (check all that apply):
African American/Black
Asian
Caucasian
Native Hawaiian/Pacific Islander
Native American/Native Alaskan
Other/Unknown
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
Any changes you make to this sheet will be permanent.
Please complete a new sheet for each new presenting experience.
Click to start a new sheet.
 
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 onePlease check only one
Victim
Family/Friend of Victim
Parent/Guardian of Victim
Allied Professional
None of the Above
Adult - Domestic Violence
Adult - Domestic Violence as a Child
Child/Youth - Domestic Violence/Abuse
Child/Youth - Exposed to Domestic Violence
None of the Above
Perpetrator Information on Presenting Domestic Violence Experience:
Please complete based on the primary presenting domestic violence incident.
Gender:
Approximate Age:
Race: (check all that apply):
African American/Black
Asian
Caucasian
Native Hawaiian/Pacific Islander
Native American/Native Alaskan
Other/Unknown
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
Any changes you make to this sheet will be permanent.
Please complete a new sheet for each date of service.
Click to start a new sheet.
 
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.
SVDVOther
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
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
Other Services (recreation, field trips, or services not named above)

Legal Advocacy Services: (Check all that apply)

 
SVDVOther
Accompaniment Services-Criminal
Accompaniment Services-Civil
Accompaniment Services-Forensic Exam
Assistance Filing For Victim's Compensation
Criminal Justice Information/Support
Assistance Filing Family Abuse EPO/PPO (Juvenile and Domestic Court)
     Family Abuse EPO/PPO Petition Awarded
     Family Abuse EPO/PPO Petition Denied
Assistance Filing for Family Abuse Protective Order (Juvenile and Domestic Court)
     Family Abuse Petition Awarded
     Family Abuse Petition Denied
Assistance Filing Protective Order EPO/PPO (General District Court)
     Protective Order EPO/PPO Petition Awarded
     Protective Order EPO/PPO Petition Denied
Assistance Filing Protective Order (General District Court)
     Protective Order Petition Awarded
     Protective Order Petition Denied
Assistance Filing for Custody/Visitation/Support
     Petition Awarded
     Petition Denied
Legal Representation (staff attorney)
 

Referrals Provided:

SVDVOther
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:

Service Contact Funded By:

VSTOP VA Victim Fund  
Any changes you make to this sheet will be permanent.
Please complete a new sheet for each new shelter stay
Click to start a new sheet.
 
Participant Code Staff/Worker

Shelter/Emergency Housing Services:

Please complete this form for each shelter stay.
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)

Service Contact Funded By:

VSTOP VA Victim Fund  

Any changes you make to this sheet will be permanent.


Participant Code Staff/Worker
Primary Victimization:
Domestic Violence
Sexual Violence
Stalking
 
Status:
Primary Victim
Secondary
 
Perpetrator Relationship to Victim: (Check all that apply)
  Current or former spouse or intimate partner
  Parent or Step-parent or Guardian
  Other family or household member
  Dating Relationship
  Acquaintance
  Stranger
  Unknown
 
Service Level
Served
Partially Served
Unserved
 
Reason (s) not Served or Partially Served: (Check all that apply)
  Conflict of Interest
  Did not meet statutory requirements
  Geographic or other isolation of victim/survivor
  Hours of operation
  Insufficient/lack of culturally appropriate services
  Insufficient/lack of language capacity
  Insufficient/lack of services for people with disabilities
  Lack of child care
  Need not Documented
  Program reached capacity
  Program rules no acceptable to victim
  Program unable to provide service due to limited resources/priority setting
  Services inappropriate/inadequate for victims with mental health issues
  Services inappropriate/inadequate for victims with substance abuse issues
  Services not appropriate for victim
  Services inappropriate/inadequate for male adolescents
  Transportation
  Unable to Contact for Follow-Up
  Other
 
Any changes you make to this sheet will be permanent.


Participant Code Staff/Worker
Primary Victimization:
Domestic Violence
Sexual Violence
Stalking
 
Status:
Primary Victim
Secondary
 
Perpetrator Relationship to Victim: (Check all that apply)
  Current or former spouse or intimate partner
  Other family or household member
  Dating Relationship
  Acquaintance
  Stranger
  Unknown
 
Service Level
Served
Partially Served
Unserved
 
Reason (s) not Served or Partially Served: (Check all that apply)
  Conflict of Interest
  Did not meet statutory requirements
  Hours of operation
  Insufficient/lack of culturally appropriate services
  Insufficient/lack of language capacity
  Insufficient/lack of services for people with disabilities
  Lack of child care
  Program reached capacity
  Program rules no acceptable to victim
  Program unable to provide service due to limited resources/priority setting
  Services inappropriate/inadequate for victims with mental health issues
  Services inappropriate/inadequate for victims with substance abuse issues
  Services not appropriate for victim
  Services inappropriate/inadequate for male adolescents
  Transportation
  Other