Hotline Services
Date of Contact Select Date (today)Primary Agency: Staff/Worker Local Only Data
Services Provided Via: Secondary Agency:
DEMOGRAPHICS OF CALLER
Gender:
Approximate Age:
Approximate Age of the Victim at Earliest Victimization:
Race/Ethnicity: (check all that apply):
African American/Black
Asian
Caucasian
Latino(a)/Hispanic
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 person identify as an immigrant/refugee/asylum seeker? Yes No N/A
3.) Does the person identify as a person with limited English Proficiency?Yes No N/A
4.) Is the person a veteran (either active duty or retired/discharged)?Yes No N/A
5.) Is this the first time this person has contacted your agency this fiscal year? Yes No
6.) Is the caller eligible for TANF (Temporary Assistance to Needy Families)? Yes No N/A
7.) Does the caller report concerns for children who have been exposed to the violence?Yes No N/A
8.) Is the person enrolled in college?Yes No N/A
9.) Does the person identify as Lesbian, Gay, Bisexual, or Queer?Yes No N/A
10.) Does the person report any current medical or health related needs, including pregnancy?Yes No N/A
11.) Does the person identify as deaf or hard of hearing?Yes No N/A
12.) Does the person identify as homeless?Yes No N/A
13.) Is this person currently incarcerated?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/Ethnicity: (check all that apply):
African American/Black
Asian
Caucasian
Latino(a)/Hispanic
Native Hawaiian/Pacific Islander
Native American/Native Alaskan
Other/Unknown
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 - Abuse/Neglect
Child/Youth - Exposed to Domestic Violence
Teen Dating 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/Ethnicity: (check all that apply):
African American/Black
Asian
Caucasian
Latino(a)/Hispanic
Native Hawaiian/Pacific Islander
Native American/Native Alaskan
Other/Unknown
Relationship to the Victim:
OTHER PRESENTING EXPERIENCE (Please complete this based on the experience of the victim)
Description of Person Receiving Services
 
Type of Other Presenting Experience
Please check ALL that apply
Adult Physical Assault    Arson   
Bullying (Verbal, Cyber, or Physical)    Burglary   
Child Pornography    DUI/DWI Incidents   
Elder Abuse or Neglect    Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other   
Homeless    Human Trafficking: Labor   
Human Trafficking: Sex    Identity Theft/Fraud/Financial Crime   
Kidnapping (non-custodial)    Kidnapping (custodial)   
Mass Violence (domestic/international)    Other Vehicular Victimization (e.g., Hit and Run)   
Robbery    Sexual Violence with Multiple Perpetrators   
Stalking/Harassment    Survivors of Homicide Victims   
Terrorism (domestic/international)   
 
No Violence Experienced   

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
Are any of the following true?
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?
12) Has the perpetrator tampered with or attempted to tamper with the victim's birth control?
13) Has the perpetrator forced or attempted to force the victim to become pregnant or to terminate a pregnancy?
14) Has the perpetrator pressured or forced the victim to do things sexually that they are not comfortable with?
 
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 are any of the following true?
SVDV
1) The child lacks a protective adult.
2) The child/youth cannot identify other trusted adults.
If yes to both statements, the advocate assisted the child 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 Seeking Family Planning Services
Assistance with Victim Compensation
Counseling/Support
Criminal Justice Information/Support
Crisis Intervention
Emergency Financial Assistance
Emergency Housing/Shelter
Immigration Assistance
Information about Victim Rights
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 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 helpfulYes No N/A
Number of Advocacy Contacts Made on Behalf of Caller: Number of Hours of Service Provided:
Service Contact Funded By:
DCJS-VSGP Fund DCJS-SAGP VDSS VSTOP
VA Victim Fund DCJS-SADVGP Other  

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