Screening Form

Directions:

1. Scan your completed Releases

2. Complete the form below and select the releases to upload.

3. Click SUBMIT

Screening Form
- Required *
- Title/Person Completing Referral: *
  
  Agency: *
  
  Phone Number: *
  
  Email: *
  
  Relationship to Client: *
  
  **Referral Source Release Form Must be completed and submitted with Screening Tool
  
  Elder Domestic Violence Shelter Screening Tool
  
  Client Name: *
  
  Date of Birth: *
  
  Age: *
  
  Sex: *
  
  Current Home Address: *
  
  City: *
  
  State: *
  
  Zip: *
  
  Where is client currently located?: *
  
  How can we ID when calling?:
  
  Best hours to call: *
  
  Reason for referral: *(Must include medical needs, limitations, safety concerns, abuse history, alternatives that have been exhausted)
  
  Perpetrator Name: *
  
  Perp Address: *
  
  Relationship of Perpetrator to victim:
  
  Married?: * Yes No
  
  Family Member: * Yes No
  
  If Yes what relationship?:
  
  Living together: * Yes No
  
  Is this the first time they were assaulted by this perpetrator?: * Yes No
  
  If No, How many times before:
  
  Does client need medical attention due to this incident: * Yes No
  
  If yes, is client going to ER : Yes No
  
  If yes, which ER:
  
  Was the victim sexually assaulted during this incident?: * Yes No
  
  Has the perpetrator sexually assaulted the victim in the past: * Yes No
  
  Were the police involved in this incident?: * Yes No
  
  Does client have a current order of protection?: * Yes No
  
  If yes, which kind:
  
  Does client wish to obtain an order of protection?: * Yes No
  
  If yes, which kind:
  
  Are there children living in the home?: * Yes No
  
  If yes, does client have custody of the children?:
  
  Names and ages of children:
  
  Have the children been abused: Yes No
  
  Did the children witness this incident?: Yes No
  
  Has CPS been notified of this incident?: Yes No
  
  Is there anyone else living in the household?: * Yes No
  
  If yes, who?:
  
  Are there pets in the home?: * Yes No
  
  Are there weapons in the house?: * Yes No
  
  If Yes, what:
  
  Is there a history of alcohol abuse/substance abuse?: * Yes No
  
  If yes, is that abuse current?:
  
  Is client currently receiving mental health treatment services?: * Yes No
  
  If Yes, please explain:
  
  Has Protective Services for Adults been contacted?: * Yes No
  
  Active Open Case?: * Yes No
  
  Has a PRI been completed?: * Yes No
  
  If yes, please attach copy:
  
  I have read/reviewed the information provided to me regarding the Elder Abuse Shelter Network. I understand that this is an application process and I agree to all application procedures and policies in order to be considered for admittance into the Elder Abuse Shelter Network.
  
  Please attach copy of signed releases:
- Enter Security Code Below: *
  
  Security code: *
  
  Answer Security Question Below: * Which number is highest 26 or 41?
  
  Answer: *