VAdata Advocacy Form

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Part I -- Preliminary Information

Participant Code:
Date Form Started:		Is Date Correct?

Staff:
Program:

Service recipient is:

Primary Victim	Secondary Victim
	If secondary, client is	Family	Significant Other	Service Provider
		Other

Reason for Advocacy	(check all that apply)
Family Violence
Sexual Assault
Stalking
Homelessness
Other

How did the victim hear about your program?

Part II -- Victim Information

Approximate Age:			Gender:			Race/Ethnicity:
Other Race/Ethnicity:

Locality:	Is victim a registered voter?	Yes	No
If locality is not on the list, please type in here:	Did victim vote in last election?	Yes	No

Education:	Does victim have health insurance?	Yes	No
	If yes, it is:	Public	Private

Is victim pregnant?

Yes

Not sure

Does victim have minor children?

Yes

If yes, list minor children's ages:

Dependent household members other than the victim's children?		If Yes, list household members by relationship and age:
Yes No

Special needs due to: (check all that apply)		Is any household member affiliated with military?
Language Interpretation		Yes
Physical/Mental Disability		No
Literacy

Victim's source of most recent income:check all that apply

Full-time employment		Partner
Part-time employment		Temporary/Migrant/Seasonal
Public Assistance		None
		Other

Victim's income is: the poverty level.

Part III -- History of Violence Experienced

What is the extent of the victim's experience with violence?

A	B	C
	Has this ever happened to you?	Has it happened in the past month?
Family violence-children	Yes No	Yes No
Family violence-adult	Yes No	Yes No
Sexual assault/rape	Yes No	Yes No
Attempted sexual assault/rape	Yes No	Yes No
Incest/sexual assault as a child	Yes No	Yes No
Adult sexually assaulted as a child	Yes No	Yes No
Stalking	Yes No	Yes No
Gang rape	Yes No	Yes No
Sexual harassment	Yes No	Yes No
Other violence	Yes No	Yes No

What is the PRESENTING experience?

Has anyone ever used a weapon, or a household object as a weapon, against you?	Yes No
Has anyone ever threatened you with a firearm or used one against you?	Yes No
Has anyone ever threatened someone you cared about?	Yes No
Has anyone ever destroyed, or threatened to destroy your property (e.g. house, car, pet)?	Yes No
Has anyone ever threatened you with physical harm?	Yes No
Have you ever sustained physical injury? (includes sexual assault)	Yes No

Part IV -- Perpetrator Information (most recent)

The perpetrator is: (relationship to victim)

Spouse	Parent	Extended Family	Acquaintance/Peer
Cohabitating Partner	Child	Other Household Member	Employer/Coworker/Supervisor/School Staff
Dating Partner	Sibling	Stranger/No Relation

Relationship is:	Current Former
If former, is separation recent	Yes No
Do perpetrator and victim have a child(ren) in common?	Yes No

If relationship is a spouse/partner, are there safety concerns such as:
Is a weapon available to partner	Yes No
Has perpetrator ever threatened you with a firearm or used one against you?	Yes No
Has perpetrator made threats of suicide/homicide?	Yes No

Is perpetrator affiliated with military?

Yes No

Perpetrator's gender:			Perpetrator's race/ethnicity:
Perpetrator's annual income:
Perpetrator's occupation:			Perpetrator's age:

Part V -- Issues Presented by Victim (not services provided by program)

What problems/concerns/fear does the victim express?

Check all issues presented by victim. In the righthand column, use the scale below to identify the three most important issues for the victim at the present time.

1=most important	2=second most important	3=third most important

Basic Life Needs

access to transportation		1 2 3
child care		1 2 3
disability-related need		1 2 3
employment/training		1 2 3
financial needs		1 2 3
household security		1 2 3
housing		1 2 3
safety planning		1 2 3
spirituality/religion		1 2 3
other basic life needs:	(specify)	1 2 3

Family/Relationship Needs

impact of violence on children		1 2 3
impact of violence on partner		1 2 3
impact of violence on extended family		1 2 3
other family impact:	(specify)	1 2 3

Health Needs

acute injury		1 2 3
ongoing physical health concern		1 2 3
immediate mental health concern		1 2 3
ongoing mental health concern		1 2 3
other health concern:	(specify)	1 2 3

Legal Needs

child custody		1 2 3
criminal re: assault		1 2 3
civil re: assault		1 2 3
defense		1 2 3
other legal need:	(specify)	1 2 3

Trauma-Related Needs

trauma of victimization		1 2 3
recovery from victimization		1 2 3
other trauma-related need:	(specify)	1 2 3

Part VI -- Self-Advocacy (complete only if new contact)

What strategies has victim employed or is in the process of using to remove threats of violence?
Ask client to rate how effective/helpful each strategy was in removing the threat of violence and maintaining her (and her children's) safety.
Use the following scale to rate strategies:

1=counterproductive	2=unhelpful	3=neither helpful/unhelpful	4=helpful	5=extremely helpful

Sought support/assistance from

family/friends		1 2 3 4 5
clergy		1 2 3 4 5
crime victims' compensation		1 2 3 4 5
financial institution		1 2 3 4 5
health provider		1 2 3 4 5
lawyer		1 2 3 4 5
other domestic violence/sexual assault program		1 2 3 4 5
social services		1 2 3 4 5
school or workplace-based services		1 2 3 4 5
therapist or other mental health provider		1 2 3 4 5
other source of support/assistance	(specify)	1 2 3 4 5

Sought intervention through

criminal sanctions		1 2 3 4 5
civil orders		1 2 3 4 5
law enforcement		1 2 3 4 5
mediation		1 2 3 4 5
school/workplace sanctions		1 2 3 4 5
military sanctions/family advocacy		1 2 3 4 5
victim witness		1 2 3 4 5
other intervention strategy:	(specify)	1 2 3 4 5

Personal intervention through

relocation		1 2 3 4 5
physical resistance		1 2 3 4 5
passive resistance		1 2 3 4 5
internal coping mechanisms		1 2 3 4 5
other strategy:	(specify)	1 2 3 4 5

Part VII -- Services Provided to Victim by Program

This page captures services provided and referrals made for the victim.
Check if service provided.

	New Service Provided for the First Time to Victim	Did program arrange/provide transportation?
Educational Services
children		Yes
extended family		Yes
partner		Yes
victim		Yes
other educational service:		Yes
Legal Services
staff attorney		Yes
staff legal advocate		Yes
referral to legal services		Yes
other legal service:		Yes
Financial Services
credit counseling		Yes
Crime Victims' Compensation		Yes
food/nutrition		Yes
fuel assistance		Yes
housing		Yes
Temporary Assistance to Needy Families		Yes
other public assistance:		Yes
Mental Health Services
therapy		Yes
referral to mental health provider		Yes
other mental health service:		Yes
Other Services
accompaniment		Yes
child care		Yes
crisis intervention		Yes
information on DV services		Yes
information on SA services		Yes
parent care		Yes
individual advocacy/counseling/support		Yes
program-sponsored group		Yes
physical health provider		Yes
safety planning		Yes
social services not previously listed		Yes
transportation (not previously listed)		Yes
other information and referral not previously listed:		Yes

Part VIII -- System Advocacy on Behalf of the Victim

Please check below any systems you have worked with in order to advocate for the client:

clergy	legal	other
education/school	mental health care
family	physical health care
financial institution	social services
health care	Victims' Compensation
housing	workplace

Part IX -- Total Number of Hours by

These totals represent number of hours of contacts in order to provide direct services and intervene in systems.

# of individual hours:	# of group hours:	# of mail hours:	# of phone hours:

Part X -- Funding Source For These Services

(check as many as apply)

VDSS - Dom. Viol.	DHCD
VFVPP-State	SSG-State
FVPSA-Federal	FSG-Federal
VOCA-Federal	Child care-Federal
	Children's Svcs. Coord-State
VDSS-Child Abuse
VOCA-State	Other
VOCA-Federal	Family and Children's Trust Fund
	United Way
DCJS	Local Government
V-STOP-Federal	Other

If this victim received services in a prior quarter (carry-over), were any NEW crimes reported during the current quarter ?
(NEW does not necessarily mean recent; it includes any crime not previously known to your center.)

Yes No