VAdata

Hotline Services
Date of Contact Select Date (today)Agency: Staff/Worker
DEMOGRAPHICS OF CALLER
Gender:
Approximate Age:
 Race: (check all that apply):
African American/Black
Asian/Pacific Islander
Caucasian
Native American/Native Alaskan
Other/Unknown
Locality of Residency (City, County, College/University, Military Base, or Out-of State): Show all localities
Does the caller 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 caller 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 caller used your program services before? Yes No N/A
Is the caller eligible for TANF (Temporary Assistance to Needy Families)? Yes No N/A
Does the caller report concerns for children who have been exposed to the violence? Yes No N/A
How did the caller learn about your program services?
PRESENTING SEXUAL VIOLENCE (Please complete this based on the violence experienced by the victim)
Check if there was NOT a presenting sexual violence experience.
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
Perpetrator
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/Pacific Islander
Caucasian
Native American/Native Alaskan
Other/Unknown
Is the perpetrator a person of Hispanic/Latino(a) Ethnicity? Yes No N/A
Relationship to the Victim:
PRESENTING DOMESTIC VIOLENCE (Please complete this based on the violence experienced by the victim)
Check if there was NOT a presenting domestic violence experience.
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
Perpetrator
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.
Click here if the perpetrator information is the same
Gender:
Approximate Age:
Race: (check all that apply):
African American/Black
Asian/Pacific Islander
Caucasian
Native American/Native Alaskan
Other/Unknown
Is the perpetrator a person of Hispanic/Latino(a) Ethnicity? Yes No N/A
Relationship to the Victim:
RISK ASSESSMENT FOR PRESENTING VIOLENCE
Please answer the following risk assessment questions for ALL victims and indicate if it is a risk for the presenting sexual violence, domestic violence or both
SV  DV
 1) If perpetrator is a former partner/spouse, is the separation recent?
 2) Has the perpetrator stalked the victim?
 3) Has the perpetrator used a weapon, or an object as a weapon against the victim?
 4) Has the perpetrator threatened to use or used a firearm against the victim?
 5) Has the perpetrator made threats of suicide and/or homicide?
 6) Has the perpetrator blocked or obstructed the victim's breathing?
 7) Has the perpetrator hurt or threatened the victim's children?
 8) Has the perpetrator hurt or threatened to harm a person or pet (other than children) the victim cares for?
 9) Has the perpetrator destroyed or threatened to destroy the victim's property?
 10) If dependent upon the perpetrator, has the perpetrator kept you from getting help with a personal need, such as eating, bathing, toileting, or access to medications?
 11) Is the victim pregnant
 
As a result of the violence, did the victim:
SV  DV
 1) Sustain physical injuries requiring emergency medical attention?
 2) Miss time from work or school?
 3) Experience a loss of income and/or financial security?
 4) Become homeless?
 5) Have to relocate?
 6) Consider Suicide?
 
If the victim is a child/youth (please read carefully, a 'yes' indicates the child is at risk):
SV  DV
 1) Is the child/youth without a protective adult in the house?
 2) Is the child/youth unable to identify other trusted adults?
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
SV  DV  Other SERVICES PROVIDED (Check all that apply)
   Accommodation Services (TTY, Language Line, Interpreter)
   Arranged Emergency Transportation
   Assistance with Victim Compensation
   Counseling/Support
   Criminal Justice Information/Support
   Crisis Intervention
   Emergency Financial Assistance
   Emergency Housing/Shelter
   Information and Referral
   Other Advocacy
   Safety Planning, including Legal Protections

Emergency Housing/Shelter 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 Service Area Doesn't Meet Criteria
        Did you arrange alternative emergency housing? Yes No N/A
SV  DV  Other REFERRALS PROVIDED (Check all that apply)
   Another Sexual and/or Domestic Violence Agency
   College/University Services
   Disability Service
   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
   Social Services
BRIEF SATISFACTION SURVEY
Did the caller receive the information requested? Yes No N/A
Did the caller report the information and/or support received as helpful Yes No N/A
Number of Advocacy Contacts Made on Behalf of Caller: Number of Hours of Service Provided:

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