VAdata

Information About Person Served

We are seeking to collect data on the numbers of people you see who SELF-IDENTIFY as transgender. Because it could be a confidentiality risk to include this data in this VAdata record, we ask you to respond to this pop-up, and the data will be stored separately with no association to this VAdata record.

Gender:

Advocacy - Information about Person Served
Date of Initial Contact Select Date (today)		Participant Code	Staff/Worker Local Only Data

Demographics of Person Served (this may not be the victim)

Gender:

Race/Ethnicity: (check all that apply):

African American/Black

Asian

Caucasian

Latino(a)/Hispanic

Native Hawaiian/Pacific Islander

Native American/Native Alaskan

Other/Unknown

Approximate Age:

Approximate Age of the Victim at Earliest Victimization:

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 person 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 the person eligible for TANF (Temporary Assistance to Needy Families)?

Yes No N/A

6.) Does the person report concerns for children who have been exposed to the violence?

Yes No N/A

7.) Is the person enrolled in college?

Yes No N/A

8.) Does the person report any current medical or health related needs, including pregnancy?

Yes No N/A

9.) Does the person identify as Lesbian, Gay, Bisexual, or Queer?

Yes No N/A

10.) Does the person identify as deaf or hard of hearing?

Yes No N/A

11.) Does the person identify as homeless?

Yes No N/A

12.) Is this person currently incarcerated?

Yes No N/A

How did the person learn about your program services?

History of Violence Experienced
Please check all that apply. Please base all responses on the violence experienced by the person being served (this my not be the victim).
Adult-Domestic Violence	Adult-Sexual Violence	Other
Victim of Domestic Violence	Victim of Sexual Violence	Violence
Victim of Domestic Violence as a Child	Victim of Sexual Violence as a Child	Stalking (Non SV/DV Related)
Family/Friend of Victim	Family/Friend of Victim
Parent/Caretaker of a Victim	Parent/Caretaker of a Victim

Child/Youth-Domestic Violence	Child/Youth-Sexual Violence
Victim of Domestic Violence/Abuse	Victim of Sexual Violence/Abuse
Victim Exposed to Domestic Violence	Victim Exposed to Sexual Violence
Family/Friend of Victim	Family/Friend of Victim
Parent/Caretaker of Victim	Parent/Caretaker of Victim

Other Reason for Advocacy-Non SV/DV Related
Homelessness
Other Service Oriented

Any changes you make to this sheet will be permanent. Please complete a new sheet for each new presenting experience. Click to start a new sheet.

Date of Contact Select Date (today)	Participant Code	Staff/Worker

Have any of the demographics for the person changed? If so, remember to update Information Sheet.

Description of Person Receiving Services:

Type of Sexual Violence Experienced:

Please check only one

Victim

Family/Friend of Victim

Parent/Guardian of Victim

Allied Professional

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:

Location of the Presenting Sexual Violence Experience:

Legal Action Related to the Presenting Sexual Violence Experience:
Did the most recent assault occur within the past 30 days?	Yes, please respond to the questions below No, please proceed to the Impact of the Presenting Sexual Violence Section Unknown, please proceed to the Impact of the Presenting Sexual Violence Section
1) Was the incident reported to the police?		Yes No N/A
2) Was the victim denied access to PERK when requested?		Yes No N/A
3) Was the victim polygraphed or asked to submit to a polygraph?		Yes No N/A
4) Has a protective order been issued?		Yes No N/A
If no, was it requested, but denied?		Yes No N/A
If yes, Protective Order issued was:		EPO PPO PO
5) Have charges been filed against the perpetrator?		Yes No N/A
If yes, charge was:		Misdemeanor Felony Both

Impact of the Presenting Sexual Violence
Concerns expressed by the person receiving services:
1.) Ability to meet basic financial needs
2.) Access to affordable and safe housing (eviction concerns, ability to meet essential housing expenses, rent, utilities, etc.)
3.) Awareness & access to community resources (how to continue to get help)
4.) Family stability (fear of abandonment, family separation, etc.)
5.) Impact of the violence on the children
6.) Impact on non-offending partner
7.) Impact of violence on non-offending parent/guardian
8.) Mental/Emotional health (fear, anxiety, sadness, shame, difficulties at work, school performance, etc.)
9.) Immigration (fear that self or others will be deported, documentation status)
10.) Legal issues
11.) Physical well-being (activity level, stress level, health issues/symptoms, sleep and eating patterns)
12.) Safety (feeling unsafe, threatened, or in danger of physical or emotional harm)
13.) Sexual and reproductive well-being
14.) Spiritual well-being
15.) Support/relationships (trust, relationships w/in the community, family & friends)
What are the primary concerns for the victim on initial contact?
Please select up to three numbers from the list above.
1.)
2.)
3.)


Self-Advocacy for Presenting Sexual Violence
Please indicate what support systems/services the person receiving services has accessed and whether or not it was helpful in responding to the violence.
		Was It Helpful?
Counseling/Support Group Services		Yes No
Going to Court		Yes No
Faith Community (e.g. congregation member, clergy)		Yes No
Family & Friends		Yes No
Hospital, Doctor, or Health Clinic		Yes No
Filing a Police Report		Yes No
Self-Defense		Yes No
Protection Orders		Yes No
Relocation		Yes No
Social Worker/Social Services (e.g. child or adult protective services)		Yes No
Another Sexual or Domestic Violence Agency		Yes No
Neighbor or Community Member		Yes No

Risk Assessment/Safety Planning
Please answer the following risk assessment questions for ALL victims. If the person being served is a child victim exposed to sexual and/or domestic violence, these risk questions may be answered based on the perpetrator’s actions against parent of the child victim.
Are any of the following true?
1.) If perpetrator is a former partner/spouse, is the separation recent?		Yes No N/A
2.) Has the perpetrator stalked the victim or the victim's parent?		Yes No N/A
3.) Has the perpetrator used a weapon, or an object as a weapon against the victim or victim's parent?		Yes No N/A
4.) Has the perpetrator threatened to use or used a firearm against the victim or victim's parent?		Yes No N/A
5.) Has the perpetrator made threats of suicide and/or homicide?		Yes No N/A
6.) Has the perpetrator blocked or obstructed the victim's or victim's parent's breathing?		Yes No N/A
7.) Has the perpetrator hurt or threatened the victim's or victim's parent's children?		Yes No N/A
8.) Has the perpetrator hurt or threatened to harm a person (other than children) or pet the victim cares for?		Yes No N/A
9.) Has the perpetrator destroyed or threatened to destroy the victim's or victim's parent's property?		Yes No N/A
10.) If dependent upon the perpetrator, has the perpetrator kept the victim or victim's parent from getting help with a personal need, such as eating, bathing, toileting, or access to medications?		Yes No N/A
11.) Is the victim or victim's parent pregnant?		Yes No N/A
12.) Has the perpetrator tampered with or attempted to tamper with the victim's birth control?		Yes No N/A
13.) Has the perpetrator forced or attempted to force the victim to become pregnant or to terminate a pregnancy?		Yes No N/A
14.) Has the peretrator pressured or forced the victim to do things sexually that they are not comfortable with?		Yes No N/A

As a result of the violence, did the victim or victim's parent (Please complete for ALL victims):
1.) Sustain physical injuries requiring emergency medical attention?		Yes No N/A
2.) Miss time from work or school?		Yes No N/A
3.) Experience a loss of income and/or financial security?		Yes No N/A
4.) Become homeless?		Yes No N/A
5.) Have to relocate?		Yes No N/A
6.) Consider Suicide		Yes No N/A

If the victim is a child/youth are any of the following true?:
1) The child/youth lacks a protective adult.		Yes No N/A
2) The child/youth cannot identify other trusted adults.		Yes No N/A
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

Any changes you make to this sheet will be permanent. Please complete a new sheet for each new presenting experience. Click to start a new sheet.

Please complete a new sheet for each new presenting experience
Date of Contact Select Date (today)	Participant Code	Staff/Worker

Description of Person Receiving Services:

Type of Domestic Violence Experienced:

Please check only one

Victim

Family/Friend of Victim

Parent/Guardian of Victim

Allied Professional

None of the Above

Adult - Domestic Violence

Adult - Domestic Violence as a Child

Child/Youth – Exposed to Domestic Violence

Child/Youth - Abuse/Neglect

Teen Dating Violence

None of the Above

Perpetrator Information on Presenting Domestic Violence Experience:

Please complete based on the primary presenting domestic 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:

Location of the Presenting Domestic Violence Experience:

Legal Action Related to the Presenting Domestic Violence Experience:
Did the most recent assault occur within the past 30 days?	Yes, please respond to the questions below No, please proceed to the Impact of the Presenting Domestic Violence Section Unknown, please proceed to the Impact of the Presenting Domestic Violence Section
1) Was the incident reported to the police?		Yes No N/A
2) Did the police request an Emergency Protective Order?		Yes No N/A
3) Has a protective order been issued?		Yes No N/A
If no, was it requested, but denied?		Yes No N/A
If yes, Protective Order issued was:		EPO PPO PO
4) Have charges been filed against the perpetrator?		Yes No N/A
If yes, charge was:		Misdemeanor Felony Both
5) Has the victim (if a child, the victim's parent) or perpetrator petitioned for custody/visitation/support?		Yes No N/A

Impact of the Presenting Domestic Violence
Concerns expressed by the person receiving services:
1.) Ability to meet basic financial needs
2.) Access to affordable and safe housing (eviction concerns, ability to meet essential housing expenses, rent, utilities, etc.)
3.) Awareness & access to community resources (how to continue to get help)
4.) Family stability (fear of abandonment, family separation, etc.)
5.) Impact of the violence on the children
6.) Impact on non-offending partner
7.) Impact of violence on non-offending parent/guardian
8.) Mental/Emotional health (fear, anxiety, sadness, shame, difficulties at work, school performance, etc.)
9.) Immigration (fear that self or others will be deported, documentation status)
10.) Legal issues
11.) Physical well-being (activity level, stress level, health issues/symptoms, sleep and eating patterns)
12.) Safety (feeling unsafe, threatened, or in danger of physical or emotional harm)
13.) Sexual and reproductive well-being
14.) Spiritual well-being
15.) Support/relationships (trust, relationships w/in the community, family & friends)
What are the primary concerns for the victim on initial contact?
Please select up to three numbers from the list above.
1.)
2.)
3.)


Self-Advocacy for Presenting Domestic Violence
Please indicate what support systems/services the person receiving services has accessed and whether or not it was helpful in responding to the violence.
		Was It Helpful?
Counseling/Support Group Services		Yes No
Going to Court		Yes No
Faith Community (e.g. congregation member, clergy)		Yes No
Family & Friends		Yes No
Hospital, Doctor, or Health Clinic		Yes No
Filing a Police Report		Yes No
Self-Defense		Yes No
Protection Orders		Yes No
Relocation		Yes No
Social Worker/Social Services (e.g. child or adult protective services)		Yes No
Another Sexual or Domestic Violence Agency		Yes No
Neighbor or Community Member		Yes No

Risk Assessment/Safety Planning
Please answer the following risk assessment questions for ALL victims. If the person being served is a child victim exposed to sexual and/or domestic violence, these risk questions may be answered based on the perpetrator’s actions against parent of the child victim.
Are any of the following true?
1.) If perpetrator is a former partner/spouse, is the separation recent?		Yes No N/A
2.) Has the perpetrator stalked the victim or the victim's parent?		Yes No N/A
3.) Has the perpetrator used a weapon, or an object as a weapon against the victim or victim's parent?		Yes No N/A
4.) Has the perpetrator threatened to use or used a firearm against the victim or victim's parent?		Yes No N/A
5.) Has the perpetrator made threats of suicide and/or homicide?		Yes No N/A
6.) Has the perpetrator blocked or obstructed the victim's or victim's parent's breathing?		Yes No N/A
7.) Has the perpetrator hurt or threatened the victim's or victim's parent's children?		Yes No N/A
8.) Has the perpetrator hurt or threatened to harm a person (other than children) or pet the victim cares for?		Yes No N/A
9.) Has the perpetrator destroyed or threatened to destroy the victim's or victim's parent's property?		Yes No N/A
10.) If dependent upon the perpetrator, has the perpetrator kept the victim or victim's parent from getting help with a personal need, such as eating, bathing, toileting, or access to medications?		Yes No N/A
11.) Is the victim or victim's parent pregnant?		Yes No N/A
12.) Has the perpetrator tampered with or attempted to tamper with the victim's birth control?		Yes No N/A
13.) Has the perpetrator forced or attempted to force the victim to become pregnant or to terminate a pregnancy?		Yes No N/A
14.) Has the peretrator pressured or forced the victim to do things sexually that they are not comfortable with?		Yes No N/A

As a result of the violence, did the victim or victim's parent (Please complete for ALL victims):
1.) Sustain physical injuries requiring emergency medical attention?		Yes No N/A
2.) Miss time from work or school?		Yes No N/A
3.) Experience a loss of income and/or financial security?		Yes No N/A
4.) Become homeless?		Yes No N/A
5.) Have to relocate?		Yes No N/A
6.) Consider Suicide		Yes No N/A

If the victim is a child/youth are any of the following true?
1) The child/youth lacks a protective adult.		Yes No N/A
2) The child/youth cannot identify other trusted adults.		Yes No N/A
If yes to both statements, the advocacte 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

Any changes you make to this sheet will be permanent. Click to start a new sheet.

Instructions: Complete this section on first contact and for each NEW incident of violence reported
	Participant Code	Staff/Worker
Date of Contact Select Date (today)	Primary Agency:
Have any of the demographics for the person changed? If so, remember to update the Information Sheet

Description of Person receiving Services:

Please select only one

Victim

Family/Friend of Victim

Parent/Guardian of Victim

Allied Professional

None of the Above

Type of Other Presenting Experience:

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

Human Trafficking: Labor

Human Trafficking: Sex

Identity Theft/Fraud/Financial Crime

Kidnapping (custodial)

Kidnapping (non-custodial)

Mass Violence (domestic/international)

Other Vehicular Victimization (e.g., Hit and Run)

Robbery

Sexual Violence with Multiple Perpetrators (must complete Presenting Sexual Violence Experience sheet for each perpetrator)

Stalking/Harassment

Survivors of Homicide Victims

Terrorism (domestic/international)

No Violence Experienced

Any changes you make to this sheet will be permanent. Please complete a new sheet for each service contact. Click to start a new sheet.

	Participant Code	Staff/Worker
Date of Service Select Date (today)



Advocacy Services & Referrals

Please fill out this section for each significant service contact (note: an individual may have more than one service contact in a day, and each contact should have its own Advocacy-Services and Referrals sheet). To be completed for shelter and non-shelter residents.
SVDVOther	INFORMATION AND REFERRAL (check all that apply)
	Criminal Justice Information/Support
	Information about victim rights, how to obtain notifications, etc.
	Information and Referral
SVDVOther	PERSONAL ADVOCACY ACCOMPANIMENT (check all that apply)
	Academic Support/Services
	Accommodation Services - Disability (TTY, Personal Care Assist, etc.)
	Accommodation Services - English not Primary Language
	Accommodation Services - Other
	Accompaniment Services - Medical
	Accompaniment Services - Other
	Assistance seeking family planning resources
	Child Care
	Education Dynamics of SV/DV
	Employment Related Services
	Immigration Assistance
	Law enforcement interview advocacy/accompaniment
	Non-Advocacy Service (any service that is not considered advocacy-this is determined by program)
	Other Advocacy Service (any advocacy service not list above)
	Services to Address Basic Needs
	Skill/Personal Development
	System's Advocacy
	Transportation
SVDVOther	EMOTIONAL SUPPORT OR SAFETY SERVICES (check all that apply)
	Counseling/Support
	Crisis Intervention
	Financial Assistance
	Group--Non-Advocacy Related
	Group--Supportive Counseling & Advocacy
	Hotline Services
	Housing Services
	On-scene crisis response
	Safety Planning Other
	Safety Planning Parent or Guardian
	Safety Planning Victim
	Therapy (licensed)
SVDVOther	OTHER (check all that apply)
	DOW survey distributed

Legal Advocacy Services: (Check all that apply)

SVDVOther
	Accompaniment Services-Civil
	Accompaniment Services-Criminal
	Accompaniment Services-Forensic Exam
	Assistance Filing a Family Abuse EPO/PPO (Juvenile and Domestic Court)
	Family Abuse EPO/PPO Petition Awarded
	Family Abuse EPO/PPO Petition Denied
	Assistance Filing a Family Abuse Protective Order (Juvenile and Domestic Court)
	Family Abuse Petition Awarded
	Family Abuse Petition Denied
	Assistance Filing a Protective Order EPO/PPO (General District Court)
	Protective Order EPO/PPO Petition Awarded
	Protective Order EPO/PPO Petition Denied
	Assistance Filing a Protective Order (General District Court)
	Protective Order Petition Awarded
	Protective Order Petition Denied
	Assistance Filing for Custody/Visitation/Support
	Petition Awarded
	Petition Denied
	Assistance Filing for Victim's Compensation
	Law enforcement interview advocacy/accompaniment
	Legal Representation
	Legal Representation for immigration relief
	Prosecution interview advocacy/accompaniment

Referrals Provided:
SVDVOther
	College/University Services
	Disability Services
	Education Services
	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
	Other Sexual/Domestic Violence Agency
	Social Services

Number of Advocacy Contacts Made on Behalf of Person Receiving Services:

Number of Hours of Service Provided:

Service Contact Funded By:
DCJS-VSGP	DCJS-SAGP	VDSS	VSTOP
VA Victim Fund	DCJS-SADVGP	Other

Any changes you make to this sheet will be permanent. Please complete a new sheet for each new shelter stay Click to start a new sheet.

	Participant Code	Staff/Worker

Shelter/Emergency Housing Services:
Please complete this form for each shelter stay.
Date of Shelter Entrance: Select Date (today)
Reason Shelter is Needed: (Check all that apply)
	DV Imminent Danger
	SV Imminent Danger
	DV Homelessness
	SV Homelessness
	Homelessness

Type of Shelter Provided: (Check only one)
	Program's Shelter Hotel Other

Legal Actions During Shelter Residence: (Check all that apply)
	Protective Order	Petitioned	Awarded	Denied
	Criminal Charges	Charged	Adjudicated
	Custody	Petitioned	Awarded
	Visitation/Support	Petitioned	Awarded
	Child Abuse/Neglect Proceedings	Reported	Investigated	Charged	Adjudicated

Date of Shelter Exit:
Select Date (today)

Victim Exited To: (Check only one)
Entered Another Shelter	Home, abuser no longer present	Home, abuser present
Left Area	Residence of friend/relative	Self-supported Housing
Transitional Housing	Other	Unknown

Transitional Housing Services:
Please complete this form for each transitional housing stay.
	Date of Entrance: Select Date (today)	Date of Exit: Select Date (today)

Service Contact Funded By:
DCJS-VSGP	DCJS-SAGP	VDSS	VSTOP
VA Victim Fund	DCJS-SADVGP	Other

Any changes you make to this sheet will be permanent.
	Participant Code	Staff/Worker

Primary Victimization:	Domestic Violence Sexual Violence Stalking

Status:
	Primary Victim Secondary

Perpetrator Relationship to Victim: (Check all that apply)
	Current or former spouse or intimate partner
	Parent or Step-parent or Guardian
	Other family or household member
	Dating Relationship
	Acquaintance
	Stranger
	Unknown

Service Level	Served Partially Served Unserved

Reason (s) not Served or Partially Served: (Check all that apply)
	Conflict of Interest
	Did not meet statutory requirements
	Geographic or other isolation of victim/survivor
	Hours of operation
	Insufficient/lack of culturally appropriate services
	Insufficient/lack of language capacity
	Insufficient/lack of services for people with disabilities
	Lack of child care
	Need not Documented
	Program reached capacity
	Program rules not acceptable to victim
	Program unable to provide service due to limited resources/priority setting
	Services inappropriate/inadequate for victims with mental health issues
	Services inappropriate/inadequate for victims with substance abuse issues
	Services not appropriate for victim
	Services inappropriate/inadequate for male adolescents
	Transportation
	Unable to Contact for Follow-Up
	Other

Any changes you make to this sheet will be permanent.
	Participant Code	Staff/Worker

Primary Victimization:	Domestic Violence Sexual Violence Stalking

Status:
	Primary Victim Secondary

Perpetrator Relationship to Victim: (Check all that apply)
	Current or former spouse or intimate partner
	Other family or household member
	Dating Relationship
	Acquaintance
	Stranger
	Unknown

Service Level	Served Partially Served Unserved

Reason (s) not Served or Partially Served: (Check all that apply)
	Conflict of Interest
	Did not meet statutory requirements
	Hours of operation
	Insufficient/lack of culturally appropriate services
	Insufficient/lack of language capacity
	Insufficient/lack of services for people with disabilities
	Lack of child care
	Program reached capacity
	Program rules not acceptable to victim
	Program unable to provide service due to limited resources/priority setting
	Services inappropriate/inadequate for victims with mental health issues
	Services inappropriate/inadequate for victims with substance abuse issues
	Services not appropriate for victim
	Services not available for victims/survivors accompanied by male adolescents
	Transportation
	Other

Any changes you make to this sheet will be permanent. Please complete a new sheet for each new housing stabalization entry Click to start a new sheet.

	Participant Code	Staff/Worker
Date Service Began

Please complete a new Housing Stabilization sheet for every adult and child who receives any service funded by a housing source. You will need to complete a new sheet for each funding source. Every sheet will require a Service Begin Date, and you will need to add a Service End Date and exit information at the time the services for each funding source end. PLEASE NOTE: you must complete this sheet for Emergency Shelter services as well in order for shelter stays to be included in your VHSP Shelter report. If the service recipient is receiving housing services from multiple funding sources, you will need a sheet for each funding source. Remember to complete a sheet for every child who is receiving services with a parent/guardian; this is required in order for children to be included in your housing reports.
Funding Source
If age 18 or older, is this adult receiving HUD services with children (either their own or children for whom they are responsible)?	Yes No N/A
Date Services Ended

For people ending any housing stabilization service, please indicate their place of residence at the time house services ended:

Information About Person Served

Presenting Sexual Violence

Presenting Domestic Violence

Other Presenting Experience

Services and Referrals

Shelter Services

VFUND

VSTOP

Housing Stabilization

Advocacy - Information about Person Served

Demographics of Person Served (this may not be the victim)

Other Demographics

History of Violence Experienced

Have any of the demographics for the person changed? If so, remember to update Information Sheet.

Legal Action Related to the Presenting Sexual Violence Experience:

Impact of the Presenting Sexual Violence

Self-Advocacy for Presenting Sexual Violence

Risk Assessment/Safety Planning

As a result of the violence, did the victim or victim's parent (Please complete for ALL victims):

If the victim is a child/youth are any of the following true?:

Description of Person Receiving Services:

Legal Action Related to the Presenting Domestic Violence Experience:

Impact of the Presenting Domestic Violence

Self-Advocacy for Presenting Domestic Violence

Risk Assessment/Safety Planning

If the victim is a child/youth are any of the following true?

Description of Person receiving Services:

Type of Other Presenting Experience:

Advocacy Services & Referrals

Legal Advocacy Services: (Check all that apply)

Referrals Provided:

Service Contact Funded By:

Shelter/Emergency Housing Services:

Legal Actions During Shelter Residence:

Date of Shelter Exit:

Transitional Housing Services:

Service Contact Funded By:

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