VAdata Legal Advocacy Form

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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?








Victim Information

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 No Not sure

Does victim have minor children? Yes No 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.

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 - as a child Yes No Yes No
Family violence - as an 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

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:

PLEASE COMPLETE FOR ALL LEGAL ADVOCACY, BOTH CIVIL AND CRIMINAL:

If known, perpetrator's prior involvement with legal system: (Check all that apply)

CRIMINAL
Family/Domestic Violence Stalking
Sexual Assault Other
CIVIL
Protective Order Other
Custody/Visitation/Support  

CIVIL LEGAL ISSUES:

Preliminary Protective Order:
Which parties were represented by attorney(s)? Petitioner Respondent Both Neither
Petition: Accepted Refused Withdrawn
Order: Issued Denied
Terms of order:
Refrain from abuse Grant possession of residence to petitioner Other Conditions
No contact with Petitioner Provide suitable alternative housing
No contact with petitioner with exception Exclusive use of vehicle
Terms of the Preliminary Order were specifically applied to the petitioner
Order:
Modified/Amended Dissolved Show Cause for Violation

Protective Order:
Which parties were represented by attorney(s)? Petitioner Respondent Both Neither
Petition: Accepted/PPO in place Refused Withdrawn Withdrawn w/Consent order in place
Order: Issued Denied
Terms of order:
Refrain from abuse Grant possession of residence to petitioner Other Conditions
No contact with Petitioner Provide suitable alternative housing
No contact with petitioner with exception Exclusive use of vehicle
Terms of the Preliminary Order were specifically applied to the petitioner
Order:
Modified/Amended Dissolved Show Cause for Violation


Custody:
Which parties were represented by attorney(s)? Petitioner Respondent Both Neither
Order Issued? Yes No History of violence presented? Yes No
Original Order Modification of Order Violation of Order
Was a guardian ad litem appointed for child? Yes No
Mediation Parent Education
Referred? Yes No Were parties ordered to Parent Education? Yes No
Did parties participate? Yes No Did the victim feel safe with the process? Yes No
Agreement reached? Yes No Did the victim find this helpful? Yes No
Did the victim feel safe with the process? Yes No
Did the victim find the process empowering? Yes No

Physical Custody to:
Mother only Father only
Mother and Father Other
Legal Custody to:
Mother only Father only
Mother and Father Other


Child Support:
Which parties were represented by attorney(s)? Petitioner Respondent Both Neither
Order Issued? Yes No
Original Order Modification of Prior Order Violation of Order
Support to be paid by: Mother only Father only

Visitation:
Who Petitioned? Mother Father Part of Custody Order
Which parties were represented by attorney(s)? Petitioner Respondent Both Neither
Order Issued? Yes No History of violence presented? Yes No
Original Order Modification of Order Violation of Order
Was a guardian ad litem appointed for child? Yes No
Visitation ordered for: Mother Father Other Times/Dates Specified? Yes No
Is the visitation exchange to be supervised? Yes No
Is the visitation with the child to be supervised? Yes No
If yes, who supervises the exchange or the visitation?
Supervised Visitation Center Family/Friend of Perpetrator
Other Public Agency Family/Friend of Victim
Other Private Agency Other


Spousal Support:
Which parties were represented by attorney(s)? Wife Husband Both Neither
Order Issued? Yes No
Original Order Modification of Order Violation of Order
Support to be paid by: Wife Husband


CRIMINAL LEGAL ISSUES:

Did the perpetrator:
use a weapon? Yes No make threats of homicide? Yes No
use a firearm? Yes No make threats of suicide? Yes No
destroy property? Yes No
inflict physical injury? No Yes, minor injury Yes, serious injury

Locality in which incident occured:

Setting where incident occured:
victim's residence public setting perpetrator's residence fraternity house
victim's workplace automobile school/university other

Were the police called? Yes No
Was an arrest made? Yes No
If not, why? Unable to locate perpetrator
Perpetrator deceased
Other
Who was arrested? Perpetrator Victim Both

Type of Charge(s):
Assault and battery
Stalking
Destruction of property
Rape
Other Sexual Assault
Criminal violation of protective order
Other 

Charge was a: Felony Misdemeanor
Both(for multiple charges)
Did the officer:
request an Emergency Protective Order (EPO)? Yes No
  Was the EPO issued? Yes No
provide information about services? Yes No
provide transportation to the victim? Yes No
make a written report? Yes No
Was a written summary of the law enforcement report made available to the victim? Yes No
Did the victim contact a magistrate? Yes No
Did the victim request an Emergency Protective Order? Yes No
If Yes, was the Emergency Protective Order Issued? Yes No
Was an arrest warrant issued? Yes No
Was an arrest made? Yes No
If not, why? Unable to locate perpetrator
Perpetrator deceased
Other
Who was arrested? Perpetrator Victim Both

Type of Charge(s):
Assault and battery
Stalking
Destruction of property
Rape
Other Sexual Assault
Criminal violation of protective order
Other 

Charge was a: Felony Misdemeanor
Both (for multiple charges)

Was the victim required to take a polygraph in order for the case to proceed? Yes No


BOND STATUS

Bond was set No bond set (perpetrator detained)
Cash/Property bond
Did perpetrator make bond (was released) ? Yes No
Were there "no contact" provisions? Yes No
Personal recognizance bond (perpetrator released)


PROSECUTION AND ADJUDICATION:

Original Charge(s):
(Check all that apply)
Charge was a:
Was charge amended to lesser charge?
Assault and battery Felony Misdemeanor Yes No
Stalking Felony Misdemeanor Yes No
Destruction of property Felony Misdemeanor Yes No
Rape Felony Misdemeanor Yes No
Other sexual assault Felony Misdemeanor Yes No
Criminal viol. of protective order Felony Misdemeanor Yes No
Other Felony Misdemeanor Yes No

Was there a trial? Yes No
Was a prosecutor present at the trial? Yes No
Trial was by: Judge Jury

 
conviction - guilty
acquittal - not guilty
dismissal
nol pros
taken under advisement/
withhold finding
deferred disposition
other
Assault and battery
Stalking
Destruction of property
Aggravated sexual assault
Rape
Other sexual assault
Criminal violation of PO
Other
SENTENCING:
Sentence/Order imposed by judge:(check all that apply)
Incarceration Fine Probation
No time suspended Restitution Community Service
Some time suspended Batterer/Sex treatment Other
All time suspended
If there was a jury, sentence recommended by jury Incarceration Fine
Time between offense and adjudication (number of months)


VICTIM SURVEY:
Victim Satisfication:
with Magistrate response Satisfied Dissatisfied
with Law Enforcement response Satisfied Dissatisfied
with the Prosecutor(s)/Commonwealth's Attorney(ies) Satisfied Dissatisfied
with the Court Satisfied Dissatisfied
with the Outcome of the Criminal Case Satisfied Dissatisfied
Were there further acts of violence between the initial offense and the adjudication? Yes No
If yes, were these crimes reported to the magistrate or law enforcement? Yes No
If no, did victim feel prior criminal response was ineffective in reducing violence? Yes No
If the crimes were reported, did charges follow? Yes No


SERVICES PROVIDED:

# of Hours# of Contacts New Services Provided for
the First Time to Victim
Provide information about legal system
Court accompaniment
Other legal accompaniment
Attorney representation
Provide information on SA/DV services
Justice system advocacy
Attorney referral
Safety planning with victim
Transportation
Dependent care
Assist children to understand legal process
Assist victim with Victim Impact Statement
Court tour
Assist victim with Victim Compensation
Follow-up legal advocacy services

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 prevously known to your center.)

Yes No

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