HELPLINE CALLER FORM

HELPLINE CALLER FORM
Advocate/Volunteer*
Date*

MonthDayYear
Date
Time*
Length of Call*
Referred by
Name of Caller*
Calling on Behalf of
Address, City, State, Zip, County
Home Phone
Work Phone Cell Phone
Cell Phone
Is it safe to call you at Home, at Work, on Cell?

NoHomeWorkCell
Abuser’s Name
Is this your first time calling Sarc?

YesNo
Have you met with SARC employee in the last 6 months?

YesNo
Is Caller Repeat Victim of Crime?

YesNo
AMAC?

YesNo
TYPE OF CALL*

DVSASTINFOSERVICE BLEND
If caller discloses the information below, fill it in here. Otherwise, you don’t need to ask these questions specifically.
Age
What is your race?
What is your marital status?
How long have you been together?
How many people are in your household?
What is your household income?
Is amount given Annual or Monthly?

AnnualMonthly
Are you a Single Head of Household?
Do you have any children?

YesNo
If yes, What are their ages and sex?
Reason for Calling:*
Suggestions Given By Advocate/Volunteer:*
Shelter Screening?*

YesNo
Crisis call?*

Crisis CallNon Crisis Call
Conclusion/Action Plan:*
INFORMATION AND REFERRALS (SARC Services are separately marked from other agencies)

SARC Only

	Info	Referral
Clinical/Counseling Services
Legal Services
Shelter Services
Helpline
AMAC (Adult Molested As Child
Safehaven for Pets
Crisis Intervention

OTHER AGENCIES

	Info	Referral	List Names/Types of Referrals Given
Housing Harford Co. Housing Assoc, etc
Other Shelters Anna’s House, HFH, etc
Police Bel Air, Aberdeen, etc
DSS Protective Services, WIC, Food Stamps, CPS, POC, etc
Medical Hospital, Clinic, Counseling, Health Department, etc
Victim Compensation Board
Other