BWRADV Online Assessment Intake Form

Black Women Revolt Against Domestic Violence

info@blackwomenrevolt.com

1.888.260.1498
Online Assessment Questions
Clients Full Name (First and Last)*
Are You Requesting Services For Yourself And Your Family?*

YesNo
If You Are Referring A Family Member Or A Client To Us To Receive Services, What Is Your Name? If this does not apply please type in N/A.*
If You Are Referring Someone, What Is The Name of the Agency You Work With And Your Telephone Number? If this does not apply please type in N/A.*
Is the individual/family member/client you are referring (for services) aware you are contacting BWRADV/making the referral? If this does not apply please type in N/A.*

YesNo
Client/Family Member's Phone Number*
Client/Family Member's E-mail*
example@example.com
Is There a Safe Time to Call Back?*
Is It Safe to Leave a Voicemail Message?*

YesNo
Do You Have a Safe Call Back Number?*
What Services Are You Seeking?*

Domestic Abuse SupportCommunity Violence SupportYouth Relationship SupportEducation or Training for ClientConsultation with CBO Case Manager/Counselor Staff
Do You Need Police Assistance?*

YesNo
Do You Need Medical Assistance?*

YesNo
Do You Have a Safe Place to Stay?*

YesNo
Do You Have a Safe Place To Talk?*

YesNo
Do You Have or Need a Good Cause Report?*

YesNo
When Was the Most Recent Incident of DV (include date and time)?*
Were the Police Called and Do You Have a Police Report or Police Report Number?*

YesNoOther
What Is Your Family Size?*
What Are Your Plans Now?*
Do You Know Where Your Abuser Is Now?*

YesNo
If yes, Tell Us Where is Your Abuser Now?*
Has Abuser Ever Stalked You?*

YesNo
Do You Currently Feel Safe?

YesNo
Do You Have Any Medical Needs Right Now?*
When Was Your Last Visit To The Doctor?*
Do You Currently Have a Support System (Family, Friend, or Victim Advocate?*

YesNo
Describe What Type(s) Of Support You Are Currently Receiving?*
What Additional Support Do You Feel That You Need?*
Any Notes About Your Current Housing Situation?*
Is There a Possibility of a Traumatic Brain Injury Due to Strangulation or Head Injury? (UCSF Trauma Clinic TBI Referral)*

YesNo
DEMOGRAPHIC INFORMATION:
Please provide this mandatory demographic information that we will use to compile a report to our funders about the age, ethnicity, and neighborhood of the clients we serve. We assure you that ALL OTHER INFORMATION ON THIS FORM IS CONFIDENTIAL.

Thank you in advance for providing this valuable information that allows us to provide these vital services to you!
Clients Age Group*

0-1617-2425-65
What best describes your race/ethnicity?*

African American/BlackAsianLatina/xSouthwestern Asian/North African (Middle Eastern)Native AmericanPacific Islander/HawaiianMultiracial/Mixed RaceOtherDecline to State
Your Zip Code*
Should be Empty:

Online Assessment Questions