Black Women Revolt Against Domestic Violence
info@blackwomenrevolt.com
1.888.260.1498
Online Assessment Questions
Clients Full Name (First and Last)
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Are You Requesting Services For Yourself And Your Family?
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Yes
No
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.
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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.
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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.
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Yes
No
Client/Family Member's Phone Number
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Client/Family Member's E-mail
*
example@example.com
Is There a Safe Time to Call Back?
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Is It Safe to Leave a Voicemail Message?
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Yes
No
Do You Have a Safe Call Back Number?
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What best describes your race/ethnicity?
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African American/Black
Asian
Latina/x
Southwestern Asian/North African (Middle Eastern)
Native American
Pacific Islander/Hawaiian
Multiracial/Mixed Race
Other
Decline to State
What Services Are You Seeking?
*
Domestic Abuse Support
Community Violence Support
Youth Relationship Support
Education or Training for Client
Consultation with CBO Case Manager/Counselor Staff
Do You Need Police Assistance?
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Yes
No
Do You Need Medical Assistance?
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Yes
No
Do You Have a Safe Place to Stay?
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Yes
No
Do You Have a Safe Place To Talk?
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Yes
No
Do You Have or Need a Good Cause Report?
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Yes
No
When Was the Most Recent Incident of DV (include date and time)?
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Were the Police Called and Do You Have a Police Report or Police Report Number?
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Yes
No
Other
What Is Your Family Size?
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What Are Your Plans Now?
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Do You Know Where Your Abuser Is Now?
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Yes
No
If yes, Tell Us Where is Your Abuser Now?
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Has Abuser Ever Stalked You?
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Yes
No
Do You Currently Feel Safe?
Yes
No
Do You Have Any Medical Needs Right Now?
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When Was Your Last Visit To The Doctor?
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Do You Currently Have a Support System (Family, Friend, or Victim Advocate?
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Yes
No
Describe What Type(s) Of Support You Are Currently Receiving?
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What Additional Support Do You Feel That You Need?
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Any Notes About Your Current Housing Situation?
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Is There a Possibility of a Traumatic Brain Injury Due to Strangulation or Head Injury? (UCSF Trauma Clinic TBI Referral)
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Yes
No
Submit
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