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Hotline Services
Date of Contact Between:
Select Date
Select Date 		Agency: Staff/Worker
DEMOGRAPHICS OF CALLER
Gender:
Approximate Age:
 Race: (check all that apply):
African American/Black
Asian
Caucasian
Native Hawaiian/Pacific Islander
Native American/Native Alaskan
Other/Unknown
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 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
2.) Does the caller 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 caller used your program services before? Yes No N/A
7.) Is the caller eligible for TANF (Temporary Assistance to Needy Families)? Yes No N/A
8.) Does the caller report concerns for children who have been exposed to the violence? Yes No N/A
9.) Is the person currently enrolled in college? Yes No N/A
10.) 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
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:
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
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:
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
SVDV
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:
SVDV
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):
SVDV
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
SERVICES PROVIDED (Check all that apply)
SVDVOther
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
REFERRALS PROVIDED (Check all that apply)
SVDVOther
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:
Service Contact Funded By:
VSTOP VA Victim Fund