Domestic Violence Crisis Hotline Call Log
Date
Time
Call Taker
Source
Survivor
Friend/Family
Agency
Other
Caller Information
Name / Alias
Phone or Contact
Relationship to Survivor
Incident Details
Type of Abuse
Immediacy of Danger
Immediate
High
Moderate
Low
Summary of Incident/Call
Actions Taken
Actions/Referrals Provided
Follow Up Needed?
Yes
No
Follow Up Details