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* Date Format: MM slash DD slash YYYY Time : HH MM 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 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?*YesNoUnknownOK to leave message with OV#?*YesNoUnknownGender (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.)Primary LanguageHistory of Sexual AbuseYesNoUnknownEver used OV services?YesNoUnknownCan 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 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.)Primary LanguageHistory 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 (sex) Human Trafficking (labor) Strangulation Other No answer Please select all that applyif "Other" please describeVictim stated offender used: Physical force Verbal threats Intimidation Weapon Please select all that applyDFSA (Drug Facilitated Sexual Assault) suspected?YesNoUnknownPlease 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 FacilityName of NurseSANE Nurse?YesNoUnknownName of PhysicianVerbal Informed Consent Was ObtainedYesNoUnknownSexual Assault Evidence Kit collected?YesNoUnknownHospital 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. 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
