Date:	Click or tap to enter a date.

Call Came in: Click or tap here to enter text. Call Ended: Click or tap here to enter text.

Name of Volunteer: Click or tap here to enter text. Call Came in on Line: Choose an item.

Language Line Used? Choose an item. Operator: Click or tap here to enter text. Time: Click or tap here to enter text. Caller Name: Click or tap here to enter text. Phone Number: Click or tap here to enter text. M ☐ or F ☐ Age: Click or tap here to enter text.

CALL TYPE	R.I.D.E.S.

Sexual Violence	☐Used Active Listening Skills

☐Sexual Assault Primary Victim	☐Identified the Problem

☐Sexual Assault Secondary Victim	☐Dealt with Feelings

☐Sexual Assault Primary PREA	☐Evaluated Options

☐Sexual Assault Other (LEO)	☐Brainstorm alternatives

☐Sexual Assault Other (PREA)	☐Identified Personal/Social resources

☐Sexual Assault Other	☐Referrals Given

☐Made Plan of Action	☐Addressed Safety Issues

NON SEXUAL VIOLENCE

☐Crisis Intervention

☐Child Physical Abuse	SERVICES PROVIDED:

☐Domestic Violence	☐Discuss with Victims Compensation

☐DUI/DWI Crashes	☐Criminal Justice Advocacy/Discuss Procedures

☐Elder Abuse/Vulnerable Adult	☐Crisis Hotline Counseling

☐Battery	☐Follow-Up Contacts

☐Burglary	☐Information and Referral

☐Innocent Victims/Gang Violence	☐Advocacy

☐Undetermined/suspicious Death	☐Information about Support Groups

☐Theft

☐Robbery

☐Survivor of Homicide

☐Grief

☐Information and Referral

☐Suicidal Ideation

☐Sudden Death Response

☐Other: Click or tap here to enter text.

SEXUAL ASSAULT RESPONSE: Caller Name: Click or tap here to enter text. Victim Name: Click or tap here to enter text.

Phone # Click or tap here to enter text. Age: Click or tap here to enter text. Reporting? Choose an item.

Injury: Choose an item. Forensic Exam Requested? Choose an item. Location: Click or tap here to enter text.

Able to Consent: Choose an item.

SEXUAL ASSAULT RESPONSE (PREA): Victim Name: Click or tap here to enter text. Age: Click or tap here to enter text.

Victim Jail ID#: Click or tap here to enter text. Forensic Exam Requested? Choose an item.

Offender Name: Click or tap here to enter text. Offender Was: Choose an item. MOD Contacted? Choose an item.

SUDDEN DEATH RESPONSE: Officer Name: Click or tap here to enter text. Phone#: Click or tap here to enter text.

Description: Click or tap here to enter text. Address: Click or tap here to enter text.

Survivor Names: Click or tap here to enter text. Advocate: Click or tap here to enter text.

PLAN OF ACTION ☐ MOD Contacted for Sexual Assault Response ☐Safety Check by ☐NPD ☐CCSO ☐Other: Click or tap here to enter text. ☐MOD Contacted for Sudden Death Response ☐Contact Eileen W.- Executive Director (back up) ☐Other: Click or tap here to enter text.

DESCRIPTION OF CALL:

Click or tap here to enter text.

☐Referrals Given to Caller Include: (attempt to give 3)

Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.

Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.

Referral List UPDATE information: (Please list any new information for the reference logs) Agency Name: Click or tap here to enter text. Phone: Click or tap here to enter text. Main Services: Click or tap here to enter text. Website: Click or tap here to enter text.

SUICIDE RISK: (Must fill in description of action taken)

☐Caller

☐Does not appear to be at risk of harm to self ☐ Appears to be at high risk of harm to self at this

HOMICIDAL RISK (Must fill in description of action taken)

☐Caller:

☐Does not appear to be at risk of harm to others ☐Appears to be at high risk of harm to others

FOR OFFICE USE ONLY:

ENTERED SVDR: ☐ Entered in Apricot – Case # Click or tap here to enter text.

☐Referred information to: Click or tap here to enter text. for follow up or info

☐Followed up with Helpline Volunteer

☐ Countable (>15 minute call)

☐ Not countable (<15minute call)

Please return original by mail or by hand to: PROJECT HELP, INC.

3050 Horseshoe Dr. N Building B, Suite 280, Naples, FL 34104.

If by e-mail send to: marcie@projecthelpnaples.org ; If by FAX to: 239-649-5520.