BWRADV Online Assessment Intake Form

Black Women Revolt Against Domestic Violence

info@blackwomenrevolt.com

1.888.260.1498 Ext. #1

Clients 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.*

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 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 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!

Clients Age Group*

0-1617-2425-65

What best describes your race/ethnicity?*

Your Zip Code*

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 to receive this protected health information.

Please select all of the organizations that you authorize Black Women Revolt Against Domestic Violence to collaborate and share information regarding your case.*

Please Provide The Name To Include In Your Release Of Information

Signature*

Online Assessment Questions