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Home
Who We Are
Mission + History
Volunteer with us
Employment and Internships
Contact Us
Donate
Healing
Options After An Assault
Advocacy Services
Therapy Services
Support Groups
Community Resources
Outreach
Events Calendar
Sexual Violence Awareness Month
Yoga from the Heartspace
Prevention
Education
Who We Serve
Empowerment
More Information
24 HOUR HOTLINE: 802.863.1236
EXIT NOW
HOPE Works Hotline Volunteer Form:
Name of Service User
*
First Name
Last Name
Date
*
MM
DD
YYYY
Advocate Initials
City/Town
Phone Number
Select Type of Inquiry
*
Primary Survivor
Secondary Survivor
General Information
Contact Method
*
Call From Service User
Web Chat
Safe To Call Back?
Yes
No
Unknown
Safe To Leave A Message?
Yes
No
Unknown (Drop For General Info)
First Time Caller?
Yes
No
Unknown
Total Time Spent**
**Please include filling out paperwork, check in calls to your back up, and follow-up messages to appropriate staff
15 Min
30 Min
45 Min
60 Min
Gender
*
Male
Female
Intersex
F -> M
M -> F
Questioning
Self Defined
Age
*
0 – 12
13 – 17
18 – 24
25 – 59
60 +
Language
*
English
Limited English Proficiency
ASL
Other
If Other:
Ethnicity
*
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Asian
Black/African American
Hispanic/Latino
White
Unknown
Other
If Other:
Please Check All That Apply
College student / affiliated with UVM
Deaf/Hard of Hearing
Disability (self-disclosed)
Homeless
Identifies as LGBTQQ
Low income
Refugee or recent immigrant
Victimization
Attempted Rape
Child Sexual Abuse
Domestic Violence
Drug Facilitated SV
Other Sexual Abuse
Rape
Sex Trafficking
Sexual Harassment
Stalking
Other
If Other:
Perpetrator Relationship
Acquaintance
Dating Relationship
Family/Household Member
Intimate Partner
Stranger
Other
If Other:
Services Provided
Information and Referral
Emotional support
Crisis Support
Safety Planning
Referrals TO (check all that apply)
COTS / Housing Organizations
CUSI / State’s Attorney / CAC
Health Centers (Planned Parenthood, CHC) HowardCenter / Disability Organizations
SafeSpace / Outright VT
SANE / Hospital
Spectrum / Youth Organizations
Support Group
Therapist List
UVM Women’s Center
Steps to End Domestic Violence
211
Other
If Other:
Referrals FROM (check all that apply)
COTS / Housing Organizations
CUSI / State’s Attorney / CAC
Health Centers (Planned Parenthood, CHC) HowardCenter / Disability Organizations
SafeSpace / Outright VT
SANE / Hospital
Spectrum / Youth Organizations
Support Group
Therapist List
UVM Women’s Center
Steps to End Domestic Violence
211
Other
If Other:
How did the user hear about agency?
Thank you!
