Source of Call
Primary Survivor
Alleged Perpetrator
Secondary Survivor
Primary Allegations
Assault Detail Information
Details of the Incident
Medical Care
Referral & Follow up
Phone Numbers Provided
Additional Interventions
Intake Notes
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Source of Call—Please choose an option—HospitalSurvivorSecondary/Referral/Other
Type of Request—Please choose an option—Hospital CallHotlineCrisis Walk-In
Advocate Name
Date of Call
Call Start Time
Call End Time
First Name:
Last Name:
Street Address:
Street Address Line 2:
City:
State / Province:
Zip Code:
County:—Please choose an option—RichlandLexingtonSumterNewberryClarendonUnknownOther
Phone number:
Email:
Date of Birth>
Biological Sex:—Please choose an option—FemaleMale
Gender Identity:—Please choose an option—FemaleMaleOther
Survivor Experiencing Homelessness:—Please choose an option—YesNo
Name
List all secondary survivors
Follow up servicesYesNo
Phone Number
Email
OK to leave messagesYesNo
Primary Allegations—Please choose an option—Adult Physical AssaultAdult Sexual AssaultAdult Survivor of Child AbuseChild Physical AssaultChild Sexual AssaultChild PornographySexual HarassmentStalkingMarital RapeSex TraffickingDomestic ViolenceUnknown
Is the Survivor experiencing more than one allegation? Check all that apply. Adult 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
Reported to Law Enforcement?—Please choose an option—YesNo
Law Enforcement Agency:—Please choose an option—Richland SDLexington SDSumter SDNewberry SDClarendon SDRichland PDLexington PDSumter PDNewberry PDManning PDOther
Investigator / Officer:
Case Number:
Has medical care been obtained? —Please choose an option—YesNoUnknown
Hospital location?
Type of Kit—Please choose an option—AnonymousSexual Assault Evidence Collection Kit
SANE Notified? —Please choose an option—YesNoUnknown
SANE Nurse—Please choose an option—RenaShellyShannonGina
Survivor request follow up? —Please choose an option—YesNo
Additional Phone Number:
Message Options:
Language Perferred:
Interpreter Needed:YesNo
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
Additional Interventions and safety planning concerns not otherwised noted:
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