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* Time : HH MM AM PM Length of Contact*in minutesContact Type* Hotline, Phone Hospital Missed Call Other (please explain below) Missed Call DetailsPlease, explain the missed call and action steps taken.Referred By* 211 Hospital Police District Attorney Friend Other (explain below) additional information about how client was referredReferred To Police Medical Shelter Helpmate Other (explain below) 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?*YesNoOK to leave message with OV#?*YesNoGender (only if the survivor told you- do not assume.)Nonbinary/Gender Non-ConformingFemaleMaleUnknownDate of BirthRace/Ethnicity (Only if the survivor told you- do not assume.)History of Sexual AbuseYesNoUnknownEver used OV services?YesNoUnknownCan OV assist the client with any of the following? Housing Income Food Employment Education Court Medical bills Law enforcement Physical/Intellectual ability Please select all that apply Secondary Victim Information (if applicable)Name First Last Address Street Address City ZIP / Postal Code Secondary Victim Phoneif unknown please type "unknown"Phone (other)OK to contact at home?YesNoOK to leave message with OV#?YesNoRelationship to victimGender (only if the survivor told you- do not assume.)Nonbinary/gender nonconformingFemaleMaleUnknownAgeRace/Ethnicity (only if the survivor told you- do not assume.)History of Sexual Abuse?YesNoUnknownEver used OV services?YesNoUnknown Assault/Assailant Information (if applicable)Gender (only if the survivor told you- do not assume.)Nonbinary/gender nonconformingFemaleMaleUnknownAgeRace/Ethnicity (only if the survivor told you- do not assume.)Relationship to victimNumber of assailantsType 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 Other Please select all that applyif "Other" please describeVictim stated offender used: Physical force Verbal threats Intimidation Weapon Please select all that applyVictim stated offender was using: Alcohol Drugs Please select all that applyVictim stated they used: Alcohol Drugs Please select all that applyDFSA (Drug Facilitated Sexual Assault) suspected?YesNoUnknownCommentsPlease include any additional details Medical Information (if applicable)Medical FacilityName of NurseSANE Nurse?YesNoUnknownName of PhysicianSexual Assault Evidence Kit collected?YesNoUnknownClient Informed of Victims Compensation?YesNoHospital Care Bag given?YesNoUnknownOur VOICE Brochure given?YesNoUnknownLaw Enforcement Information (if applicable)Name of DetectiveName of Officer(s)Law Enforcement AgencyReport filed?YesNoUnknownArrest made?YesNoUnknownBlind report filed?YesNoUnknown Client Follow UpWould client like a follow-up from OV?*YesNoUnknownFollow-Up InformationPlease include any specific requests, questions, or referrals the client may need assistance with. Additional InformationPlease include any additional information from the client contactCrisis Basepoint*Please enter a number from 1 to 5.On a scale of 1(low) to 5(high) how would you rate the client's crisis level?Explanation of Crisis Basepoint
