Client Contact Report Form Client Contact Report Form Volunteers are required to complete and submit this form following any contact with clients. Step 1 of 6 16% Contact InformationVolunteer/Staff Name* First Last Email Date* MM slash DD slash YYYY Time : AM PM Length of Contact* in minutesContact Type* Hotline, Phone Hospital Missed Call No answer Other (please explain below) Missed Call DetailsPlease, explain the missed call and action steps taken.Referred By* TASCO Hospital Police RHA or other mental health service Friend Other (explain below) additional information about how client was referred additional information about how client was referredReferred To Police Medical Shelter Helpmate Other (explain below) Additional information about client referral Additional information about client referral Primary Victim InformationName First Last Pronouns (remember to ask the survivor!) Pronouns (he/him, she/her, they/them, ze/hir, etc.) Address Street Address City ZIP / Postal Code Phone* if unknown please type "unknown"Phone (Other)OK to contact at home?* Yes No Unknown OK to leave message with OV#?* Yes No Unknown Gender (only if the survivor told you- do not assume.) Nonbinary/Gender Non-Conforming Female Male Unknown Date of Birth Race/Ethnicity (Only if the survivor told you- do not assume.) Primary Language History of Sexual Abuse Yes No Unknown Ever used OV services? Yes No Unknown Can OV assist the client with any of the following? Housing Mental Health Resource Other county SV crisis center Food Income Employment Education Court Medical bills Law enforcement Physical/Intellectual ability Transportation (for WNCAP) Transportation (in general) Please select all that apply Secondary Victim Information (if applicable)Name First Last Address Street Address City ZIP / Postal Code Secondary Victim Phone if unknown please type "unknown"Phone (other)OK to contact at home? Yes No OK to leave message with OV#? Yes No Relationship to victim Gender (only if the survivor told you- do not assume.) Nonbinary/gender nonconforming Female Male Unknown Age Race/Ethnicity (only if the survivor told you- do not assume.) Primary Language History of Sexual Abuse? Yes No Unknown Ever used OV services? Yes No Unknown Assault/Assailant Information (if applicable)Gender (only if the survivor told you- do not assume.) Nonbinary/gender nonconforming Female Male Unknown Age Race/Ethnicity (only if the survivor told you- do not assume.) Relationship to victim Number of assailants Type of Assault* SA on adult SA on child Attempted Rape Marital Rape Rape Incest Date Rape Statutory Rape Harassment/Stalking Domestic Violence Adult Survivor of prior SA Human Trafficking (sex) Human Trafficking (labor) Strangulation Other No answer Please select all that applyif "Other" please describe if "Other" please describeVictim stated offender used: Physical force Verbal threats Intimidation Weapon Please select all that applyDFSA (Drug Facilitated Sexual Assault) suspected? Yes No Unknown Please provide 1-2 sentences briefly describing the facts of the assault (such how recent, where, who was involved, etc.) Refrain from opinions/subjective observations. Do not include incriminating statements about survivor (such as "the survivor was on drugs" or "the survivor could not remember")Please include any additional detailsPlease provide 1-2 sentences stating any specific needs the client had (for example, grounding tools, counseling, housing, etc.)Please include any additional detailsPlease provide 1-2 sentences stating specific what you provided to the client (for example, told about counseling, helped deescalate, reassurance, etc.)Please include any additional details Medical Information (if applicable)Medical Facility Name of Nurse SANE Nurse? Yes No Unknown Name of Physician Verbal Informed Consent Was Obtained Yes No Unknown Sexual Assault Evidence Kit collected? Yes No Unknown Hospital Care Bag given? Yes No Unknown Our VOICE Brochure given? Yes No Unknown Law Enforcement Information (if applicable)Name of Detective Name of Officer(s) Law Enforcement Agency Report filed? Yes No Unknown Arrest made? Yes No Unknown Blind report filed? Yes No Unknown Client Follow UpWould client like a follow-up from OV?* Yes No Unknown Follow-Up InformationPlease include any specific requests, questions, or referrals the client may need assistance with. Crisis Basepoint*Please assess the caller's crisis basepoint as it was at end of your contact with them. Crisis basepoint is an assessment of whether caller's foundational needs (housing, safety, support system, emotion regulation) are met and how effectively they are coping with what is going on. 1- foundational needs are met; coping mechanism do not need to be utilized (possibly an informational call or a third-party caller) 2- foundational needs may be at-risk; coping mechanism have been identified and are being utilized effectively 3- foundational needs are not stable; unable to identify or utilize coping mechanism effectively 4- foundational needs are unmet; coping mechanisms are ineffective 5- suicidal or self-harm ideation No answer
