BWRADV Online Assessment Intake Form

Black Women Revolt Against Domestic Violence

info@blackwomenrevolt.com

1.888.260.1498 Ext. #1
Online Assessment Questions
Client's Full Name (First and Last)*
*An Address Is Required. Please use your address, the address of the agency referring you or BWRADV, 1485 Bayshore Blvd. MB 122, San Franciso, CA 94124*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are You Requesting Services For Yourself And Your Family?*

YesNo
Your Birthdate is REQUIRED. If you do not wish to list your age, please enter 01-01 and your Birth Year.*

MonthDayYear
Date
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 check N/A.*

YesNoN/A
Client/Family Member's Phone Number*
Format: (000) 000-0000.
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?*
Is This A Safe Number To Text Information To You? *
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 the Police Report Number? (If you have it)
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? PLEASE NOTE: We do not provide housing.*
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!
Client's 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*
What is your Gender?*
How do you describe your sexual orientation or sexual identity? (Select One)*
What gender pronouns do you use? (Optional)
By what name do you wish to be called? (Optional)
What is your primary language spoken at home? (Mark ONE)*
Are you a veteran?*
Are you a person with a disability?*
What best describes your family? A family includes a single person or a group of people living together. (Mark ONE)*

Single headed familyDual headed family
Number of persons living in your family (including yourself):*
Estimated income for the next 12 months for all adult members of your household:*
Do you receive any type of public assistance? (Mark ALL that apply).*

CalWorksCalFreshCash assistance linked to Medi-CalCash Assistance Program for ImmigrantsCounts Adults Assistance ProgramMedi-CalSocial Security DisabilityRefugee Cash AssistanceSupplemental Security IncomeOther
What source of information were used to verify your income? (Mark ALL that apply)

Pay RollPlaced in foster carePublic benefitsVeteran BenefitsUnemployment BenefitsRental assistance (Section 8 Voucher)Self certifiedTax Return
What source of information were used to verify your income? (Mark ALL that apply)*

Public benefits (Mark here if you chose any option in the previous question)Pay RollTax ReturnUnemployment BenefitsVeteran BenefitsRental Assistance (Section 8 Voucher)Placed in Foster CareSelf CertifiedOther
I hearby certify that, to the best of my knowledge, the above statements are true and correct. I understand this information is subject to verification only by authorized US Department of housing and urban development officials for federally funded grants.*
Our funder, MOHCD collects data on race, ethnicity, sexual orientation and gender identity, in order to ensure the programs and services they fund are addressing the needs of the vulnerable communities we serve, and to report anonymous information to Key funders like HUD. MOHCD protects your personally identifiable information PII) from lost, theft, misuse, and unauthorized access and disclosure. PII includes your name, address, birthdate, race, and ethnicity, gender, sexual orient/identity, and household size and income Also, PII is never necessary to achieve the purposes noted above. I understand that this information is being requested on behalf of our funder and not on behalf of Black Women Revolt Against Domestic Violence.*
RELEASE OF INFORMATION

I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, or by contacting us at (888) 260-1498, extension. 1 for assistance to revoke your consent.

* I understand that this consent is for (one) 1-year after this is signed and this consent automatically expires at that time.

* I have been informed what information will be given, its purpose, and who will receive the information.

* I understand that I have a right to receive a copy of this authorization.

* I understand this release of information to the following agencies is voluntary, and you may revoke

* I understand that this information may be protected by Title 45 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 42 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws.

* I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.

If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization in the field below to receive this protected health information.
Upload Here

Cancelof
Please Provide The Name To Include In Your Release Of Information*
Signature*
Please select all of the organizations that you authorize Black Women Revolt Against Domestic Violence to collaborate and share information regarding your case.*

APA FamiliesBay Area Legal AidBooker T Washington Community Service Center (BTWCSC)Children's Council of San Francisco (Subsidized Childcare)Communities United Against Violence (CUAV)Compass Family ServicesCooperative Restraining Order Clinic (CROC)Homeless Prenatal Services (Client and Housing Services)Family Children Services (FCS)Mayor's Office of Victims RightsSan Francisco District Attorney's OfficeSan Francisco Sheriff's Dept.SisterWebSt. Anthony's FoundationThe Honeycomb ClinicU.C.S.F. Trauma Recovery CenterW.O.M.A.N. Inc. (Emergency DV Shelter Referral)Young Women's Freedom CenterNone Of The Agencies Listed AboveOther
Other Agencies to Receive Your Release Of Information
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Online Assessment Questions