Companion Form

Companion Report Form
Advocate/Volunteer*
Date*

MonthDayYear
Date
Arrival Time*
Length of Companion*
Hospital: AMC/UCMC
Case Type: DV/SA/HT*
SAFE Nurse:
If client discloses the information below, fill it in here. If you don't receive all information- that is okay. We are here to support in any capacity that we can.
Client Name
Safe Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB

MonthDayYear
Date
Is it safe to call you at Home, at Work, on Cell?

NoHomeWorkCell
Abuser’s Name
Abuser Type

StrangerAcquaintanceDatingMaritalUnknown
Were police contacted?

YesNo
Precinct:
Officer Name/Badge Number
Verbal Release to provide information to SART?

YesNo
Follow Up Service Requested?

YesNo
Safety Plan Completed?

YesNo
Summary of companion visit:
Suggestions Given By Advocate/Volunteer:*
Shelter Screening?*

YesNo
INFORMATION AND REFERRALS (SARC Services are separately marked from other agencies)

SARC Only

OTHER AGENCIES

	Info	Referral	List Names/Types of Referrals Given
Housing Harford Co. Housing Assoc, etc
Other Shelters Anna’s House, HFH, etc
DSS Protective Services, WIC, Food Stamps, CPS, POC, etc
Health Department, Counseling etc
Protective Order
Other

*A legal referral to another agency will be given by SARC Legal Staff only.

Please submit completed companion report to Client Services by the following business day either by drop off or completing this form on website
Should be Empty:

Companion Report Form