Get Sexual Assault History Form / 2017 A. Survivor Information B ...

Filling out the Sexual Assault History Form is an important step for survivors seeking support. This guide provides step-by-step instructions on how to fill out this sensitive form online, ensuring clarity and ease throughout the process.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Begin with the 'Name of Agency' section. Enter the name of the agency providing the support.
3. In the 'Client Identifier' field, input a unique identifier for the survivor to ensure confidentiality.
4. Proceed to section A, 'Survivor Information'. Indicate the date of the most recent sexual assault/abuse incident using the provided format (month/year).
5. Fill in the survivor's age at the time of the most recent incident and their current age in the respective fields.
6. In the Survivor Sexual Orientation section, check all options that are applicable. Provide responses for gender identity as per previous instructions.
7. Complete the Survivor Ethnicity/Race section by selecting one option that best describes the survivor's background.
8. Indicate any disabilities the survivor may have, checking all that apply.
9. Answer questions about substance use prior to or during the incident and any sexually transmitted diseases that may have resulted from the assault.
10. Include information about any pregnancies resulting from this incident, and previous incidents of domestic violence or sexual assault when applicable.
11. In section B, 'Offender Information', provide details about the offender(s) involved, choosing one for questions 15-27 if there are multiple offenders.
12. Continue filling out the type of offense and relationship between the survivor and the offender as per the options provided.
13. Complete questions regarding the survivor's report and any injuries sustained, as well as medical treatment inquiries.
14. Finally, review your responses for accuracy. Once completed, save changes, download, print, or share the form as needed.

Take the first step towards healing by completing your forms online today.