Source of CallHospitalSurvivorSecondary/Referral/Other
Type of RequestHospital CallHotlineCrisis Walk-In
Advocate Name—Please choose an option—Abunijem, LanaAl-Khalil, MeganAlston-Johnson, CynthiaAnderson, MawasiBell, NicoleBegley, RachelBizzell, MichelleBonnett, StephanieBrennen, HannahBrigman, CarolineBruce, CaitlinBryan, RebeccaBuford, LeannaBurton, AveryCarson, CarolinCarraway, Aiko MarieConwell, SavannahCorn, HayleyCranford, DavidCredle, GwendolynCrotty, ErinCurtin, JulietDantzler, WilliamDavis, DonnaDemino, CatherineDixon, LexieDoughty, JessaDuke, TylerFalous, HudaFleifel, SamanthaFobare, RachelFolk, Yuanita, F, YuanitaFolkart, KatiaFry-Kendall, TianaFullard, JasonFulmer, RaeganFerguson, SkyeGfell, AmyGhosh, AnushaGibson, LisaGibson, SarahGillespie, KaseyGrant, DianeGray, EmilyHammond, LeahHansen, MakaylaHarris, BunnieHarrison, AllysonHarvin, MikiaHatfield, KellyHatrick, RebeccaHayes, NiycerriahHogg, IraHoller, OwingsHowe, EmilyJarvis, VanessaJones, KelseyKilgore, KelleyKing, RachaelKothadia, RohanKuchman, CharlieLahiri, NayeliLandy, JoanneLawton, SandreaLeMoine, MichelleLeuthauser, LaikenLevy, CatherineLewis, Johna'eLightbourne, MalikaLorick, RebeccaMacatiag, BrielleManess, MarieMarcotsis, AlexMarks, CrystalMartin, MakaylaMason, CameronMellette, MelissaMenzies, MontanaMesa, AleajndraMckan, DeliciaMesser, KaitlynMiddleton, GermaineMillhouse, UnikaMunn, MarryMurphy, TiffanyMyers, AnnaNieto Hernandez, IrisO'Grady, KaylaOliver, AmandaPack, LoteriaPalmore, JaylishaPatel, EshaPatel, RohitaPearlstein, AnnaPedersen, EmmaPerry, CharlottePhelan, MollyPhillips, SaraPillsbury, SarahPinkney, MawatiPinkney, RachmawatiPollock, AlishaPridgen, EmilyRandazzo, SiciliaRaven, CourtneyRavi, SreshtaRichardson, MaggieRobins, AlexandraRodriguez, EsmeraldaRomine, OliviaRucki, KarissaSalter, KrystalSattele, JennaSawyer, HannahScurry, ShaySeebach, RachelShaiman, SophiaShearin, BrittanySims, RaquelSmith, CharitySmith, HollandSommer, GraceSpenser, ShamonicaSteverson, KathrynSweeny, MiaSwords, CarolineTabb, TammieTarekegne, MelatTaylor, JenniferTaylor, KimberlyTaylor, PhyllisTodd, SaraTorgersen, SofiaTorres, TinaWalling, JenniferWalsh, LizWalton, JanaeWelsh, SydneyWesley, ArielWieder, ParkerWilliams, AngelaWilliams, AzariaWilson, MargaretWolfe, ElizabethWright, BarbaraYeung, AnthonyYoung, EmilynZuluaga, Laura
Date of Call
Call Start Time
AMPM
Call End Time
Primary SurvivorSurvivor Unidentified
Name (First,Last)
Age
Date of Birth
Biological SexFemaleMale
Gender IdentityFemaleMaleTransgenderGender Non-Conforming
Race—Please choose an option—Asian / Pacific IslanderBlack (Not Hispanic)HispanicNative AmericanWhite (Not Hispanic)BiracialUnknownOther
Primary Allegations (Reason for Call)Adult Physical AssaultAdult Sexual AssaultAdult Survivor of Child AbuseChild Physical AssaultChild Sexual AssaultChild Pornography Sexual HarassmentStalkingMarital RapeSex TraffickingDomestic ViolenceUnknown
Is the Survivor experiencing more than one Allegation? Check all that applyAdult Physical AssaultAdult Sexual AssaultAdult Survivor of Child AbuseChild Physical AssaultChild Sexual AssaultChild PornographySexual HarassmentStalkingMarital RapeSex TraffickingDomestic ViolenceUnknown
Assault Detail InformationAttemptedAnalDigitalNon penetrated TouchOralVaginalUnknownOther
Incident Date
Incident County
Drugs/Alcohol InvolvedYesNoUnknown
CoercionHandsKidnappingRestraintVerbal Weapon
Weapon
Reported to Law EnforcementYesNoUnknown
Date Reported
Agency Richland SDLexington SDSumter SDNewberry SDClarendon SDUnknownRichland PDLexington PDSumter PDNewberry PDManning PDOther
Other
Investigator/Officer:
Case Number:
Does the Survivor have injuries?VisibleNon-visibleNoneUnknown
Has medical care been obtained?YesNoUnknown
Date Received:
Type of Care:Anonymous KitGYN ExamSTISTD ScreeningSexual Assault Evidence Collection KitHIV ProphylaxisMedical onlyPlan BPregnancy Test
Hospital Location:PH RichlandPH BaptistPH ParkridgePH TuomeyLexingtonNewberryMcLeodUnknownOther
SANE Notified?YesNoUnknown
Dr:
Nurse:
SANE:
Clothing Provided?YesNoUnknown
Survivor Handbook Provided?YesNoUnknown
Survivor Request Follow up?YesNo
Address Type:HomeIncarceration-Institution:
—Please choose an option—Broad River Correctional InstitutionKirkland Correctional InstitutionManning Correctional InstitutionCamille Graham Correctional InstitutionTurbeville Correctional InstitutionGoodman Correctional InstitutionWateree River Correctional InstitutionUnknown Correctional InstitutionAlvin S. Glenn Detention CenterLexington County Detention CenterOther
Inmate Number:
Survivor Experiencing Homelessness?YesNoUnknown
Address
City
State
Zip Code:
County:RichlandLexingtonSumterNewberryClarendonUnknownOther
Other:
Phone Number:
Ok to CallOk to VoicemailCellMainHomeWork
Additional Phone Number:
Email:
Permission to send email:YesNoUnknown
Language Perferred:
Interpreter Needed?YesNoUnknown
Was Survivor referred to PTH?YesNo
Referral Source Agency:
Referral Source:
Was Survivor referred by PTH?YesNo
Referral Agency:
Phone Numbers ProvidedNational Sexual Assault Hotline RAINN 1-800-656-4673National Human Trafficking Center 1-888-378-8888Substance Abuse and Mental Health Services Administration 1-800-662-4357National Suicide Prevention Lifeline 988National Alliance on Mental Health 1-800-950-6264Department of Defense Safe Helpline 1-877-995-5247Department of Crime Victims 1-800-220-5370
Reported to DSS?YesNoUnknown
Previous DSS involvement:YesNoUnknown
Emergency Protective Custody:YesNoUnknown
Agency
Caseworker
Contact Number
Other Involvement (Military, College, Domestic Violence):YesNoUnknown
Advocate
Alleged PerpetratorPerpetrator Unidentified
Name
Relationship to Survivor
History of Drug/Alcohol Abuse?YesNoUnknown
History of Abuse to others??YesNoUnknown
Survivor Request Follow up?YesNoSurvivor Unidentified
Name:
Age:
Date of Birth:
Relationship to Survivor:
Official notes for case file:
Advocate Initials
Post It note for intake team only
Submit
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