Call Out Form | Victim Services

Call Out Form

LIMITS OF CONFIDENTIALITY
Victim Services of Bruce Grey & Owen Sound is a confidential service. We will not willingly disclose information received in confidence. Exceptions being in the event of suspected child at risk (mandatory reporting immediately to Children’s Aid Society and Coordinator), threat of danger to community or self (re-contact police or other appropriate agency), information to VS staff required follow up call (call may be declined), or critical information related to ongoing investigation (encourage victim to disclose to police), court orders or statute…..

If you would like to download and print the call out form please right click this link and choose "save as" to save the document to your computer.

If your are choosing to Phone or Fax the information into the Owen Sound Office Please call 519-376-7474/1-888-577-3111 or fax: 519-376-0865.

Date: *

Type of Call: *
On Scene

Phone

On Scene Location:

On Scene Arrival Time:

On Scene Return Time:

Phone Contact Made:
Yes

No

Message Left

Phone Number of Attempts:

Phone Time of Contact:

Phone Time Spent (Minutes):

Volunteer: *

Mileage # of KM:

Debriefed:

Volunteer:
Only required for On Scene

Mileage # KM :

Debriefed:

Shift Coordinator Notified: *
123

911

111

Shift Coordinator: *
Heidi

Mary Kay

Char

Tracy

Dawn

Mary

Linda

Client Name: *

Phone:
****REMEMBER *67****

Address:

Call Type: *
Abduction

Assault (Domestic)

Assault (All Others)

Break & Enter

Criminal Harassment

Elder Abuse

Homicide

M/Vehicle Collision

Robbery

Sexual Assault

Theft/Fraud

Vandalism

Other Crime Related Occurrence

Tragic Circumstance (See below)

If You Chose Tragic Circumstances please choose one of the following:
Accommodation Crisis

Family Occurrence

Fire

Medical Crisis

Missing Person

Personal Crisis

Sudden Death

Suicide

Disaster

Threatened Suicide

Source of Referrals Received: *
Police Services

Health Organizations

Violence Against Women Services

EMS

Other (including self referral)

Name of Referring/Requesting Agency:
Including name of officer if Police Services was referring agency

Clients Present At Intervention - # of Adult Males:

Clients Present At Intervention - # of Adult Females:

Clients Present At Intervention - # of Children 0-15:

Practical Assistance Provided (please choose all that apply):
Transportation

Clothing

Food

Brochure / Handouts

Childcare

Accommodation

Personal Hygiene Products

Other

Please describe Practical Assistance Provided if Applicable:

Health Care Services:
Family Dr.

Grey Bruce Regional Health Services

South Bruce Grey Health Services

Mental Health Services:
Brief Counseling

Canadian Mental Health Association (CMHA)

Community Mental Health Teams

Family Support Initiative

Mental Health Court Support Services

Mental Health Crisis Line of Grey Bruce

Shelters:
Dbinooshnowin Cape

Kabaeshiwin Saugeen

Women's Centre Grey

Women's House Bruce

Bereavement:
Brief/Grief Counseling

Clergy

Employer Assistance Program

Funeral Director

MADD Canada

Sexual Assault Centers:
EARS for Men

M’Wikwedong Native Cultural Resource Ctr

Sexual Assault Services

Sexual Assault & Partner Abuse Care Center

VWAP:
VWAP

Other:
Addiction Day Treatment Program

Alcoholics Anonymous

Al-Anon

Alzheimer’s Society

Adult Protective Services

Bruce County Housing Corp

Bruce County Social Services

CAS - Bruce

CAS - Grey

Choices

Church Community

Community Care Access Centre

Community Legal Clinic

Community Living

E.A.P.

Family Law Information Centre

G&B House

Good Food Box

Grey County Housing Corp

Home & Community Support

Insurance Company

Keystone Child/Youth Services

Kids Help Line

Lawyer Referral Service

Local Food Bank

New Directions

Non-Profit Credit Counseling

Ontario Works

Police

Salvation Army (O.S./Wiarton/Port Elgin)

Service Ontario (Gov’t Bldg)

Senior’s Advocacy & Awareness Network (SAAN)

Supervised Access Program

The Men’s Program

Victim Services (outside area)

Y Employment Services

Y Housing

Other Referrals not Listed:

Comments/Needs of Victim:

CAS Notified (Children at Risk under 16 years of age):
Yes

No

CAS Grey: 376-7893 / 1-866-259-4823 CAS Bruce: 881-1822 / 1-800-461-1993

Safety Plan Provided: *
Yes

No

Refused

Not Applicable on this call

MANDATORY ON DOMESTICS

Verbal Consent:
Yes

No

Don't Forget VWAP Referral when charges have been laid VWAP#519-376-8927 / 1-866-259-4823

Follow Up Required:
Yes

No

Date:

Time:

Phone:

If No Reason:

Package to be Sent: *
Yes

No

Material Requested:

Address:
If different

Date: *

Type of Call: *

On Scene

Phone

On Scene Location:

On Scene Arrival Time:

On Scene Return Time:

Phone Contact Made:

Yes

No

Message Left

Phone Number of Attempts:

Phone Time of Contact:

Phone Time Spent (Minutes):

Volunteer: *

Mileage # of KM:

Debriefed:

Volunteer:

Only required for On Scene

Mileage # KM :

Debriefed:

Shift Coordinator Notified: *

123

911

111

Shift Coordinator: *

Client Name: *

Phone:

****REMEMBER *67****

Address:

Call Type: *

If You Chose Tragic Circumstances please choose one of the following:

Source of Referrals Received: *

Name of Referring/Requesting Agency:

Including name of officer if Police Services was referring agency

Clients Present At Intervention - # of Adult Males:

Clients Present At Intervention - # of Adult Females:

Clients Present At Intervention - # of Children 0-15:

Practical Assistance Provided (please choose all that apply):

Please describe Practical Assistance Provided if Applicable:

Health Care Services:

Family Dr.

Grey Bruce Regional Health Services

South Bruce Grey Health Services

Mental Health Services:

Brief Counseling

Canadian Mental Health Association (CMHA)

Community Mental Health Teams

Family Support Initiative

Mental Health Court Support Services

Mental Health Crisis Line of Grey Bruce

Shelters:

Dbinooshnowin Cape

Kabaeshiwin Saugeen

Women's Centre Grey

Women's House Bruce

Bereavement:

Sexual Assault Centers:

EARS for Men

M’Wikwedong Native Cultural Resource Ctr

Sexual Assault Services

Sexual Assault & Partner Abuse Care Center

VWAP:

VWAP

Other:

Other Referrals not Listed:

Comments/Needs of Victim:

CAS Notified (Children at Risk under 16 years of age):

Yes

No

CAS Grey: 376-7893 / 1-866-259-4823 CAS Bruce: 881-1822 / 1-800-461-1993

Safety Plan Provided: *

Yes

No

Refused

Not Applicable on this call

MANDATORY ON DOMESTICS

Verbal Consent:

Yes

No

Don't Forget VWAP Referral when charges have been laid VWAP#519-376-8927 / 1-866-259-4823

Follow Up Required:

Yes

No

Date:

Time:

Phone:

If No Reason:

Package to be Sent: *

Yes

No

Material Requested:

Address:

If different