1
TECHNICAL ASSISTANCE FORM
ALL INFORMATION MUST BE FILLED OUT UNLESS SPECIFIED
CALL INFO
CALLER INFORMATION
STAFF/CONSULTANT
DATE
CONTACT INFORMATION
You can search the
internet to try to get
information based on
organizational names
Recipient Of T.A.
Check only one box and
guess the best box that
applies if there is overlap:
Topics of Technical
Assistance
Check All that Apply:
Attorney Name:
Date of Initial Contact:
Name:
Title:
Address:
Telephone:
Fax Number:
Non-Legal Advocate:
Batterer Intervention Program
Culturally specific Programs
Disability/Deaf Organization
Domestic Violence Program
Dual DV/SA Program
Elder Abuse/Aging Program
Faith-based organization
Forensic Examiner Program
Health Care Provider
Mental Health Care Provider
Other National TA Providers
Sexual Assault Program
Stalking Program
State/Tribal/Territory Coalitions
Supervised Visitation Program
Transitional Housing Program
Tribal DV/SA Program
University/campus Program
Student_________________
Professor's Name
Attorney:
Attorney (also check one below)
Crim. Defense Att./Public Defender
DV Attorney
Family Law Attorney
Immigration Attorney
Law School Professor
Legal Services Attorney
Law Firm Pro Bono
Poverty Law Attorney
Other:
Intern Name:
TA Completed Date:
Name of Organization:
Immigration
Asylum
Battered Spouse Waiver
Enforcement/Detention
General Immigration
Immigration Court
T-Visa
Trafficking
U-Visa
VAWA Confidentiality
VAWA Self-Petition
Benefits
Cash Benefits
Education
Food/Nutrition
Health
Mental Health
Public Housing
Transitional Housing
Other
Email:
Website:
Government:
Adult Protective Services (APS)
Child Protective Services (CPS)
Coordinating Council/Taskforce
Corrections
Court
Family Justice Center
Federal/State Gov Agency (also check one below:)
OVW
STOP/VAWA State Grant Administrator
FVPSA State Grant Administrator
VOCA State Grant Administrator
DHS
DOE
HUD
DOJ
Other Federal Gov
Other State Gov
Law Enforcement
Prosecutor
Tribal Government
Individuals (person seeking help for him/herself):
Collect minimal information to provide referrals only.
Yes
No Asked if safe to leave a message or
alternative safe contact information?
Yes
No Does the individual have an attorney?
If yes, Interns stop TA and consult an IWP attorney
Other:
Funder
Media
1101 14th Street, NW Suite 300 Washington, DC 20005 Tel 1
202-326-0040 Fax 202-589-0511 www.legalmomentum.org
2
Topics of Technical
Assistance Continued
Check All that Apply:
Family Law
Child Custody
Divorce/Annulment
Domestic Violence
Economic Issues (Support)
Elder Abuse
Full Faith & Credit
Protection Order
Protection Order Enforcement
Supervised Visitation and Exchange
Termination of Marriage
VAWA Confidentiality in Family Court
CALL INFORMATION
Other Legal
Civil Legal Services
Court Response
Confidentiality
Criminal Codes
Employment
Fatality Review
Forensic Evidence
Law Enforcement Response
Probation and Parole Response
Prosecution
Other
Response to Victims
Other identification
needed for grant
reporting (do not need to
ask specifically but please
note if it comes up)
Is The Individual A Victim Of:
Domestic Violence
Elder Abuse
Human Trafficking
Sexual Assault
Stalking
Other crimes:
Individual:
has a mental health issue
has a substance abuse issue
identifies as LGBTQ
is an immigrant
is deaf
is disabled
is homeless
is Limited English Proficient (LEP)
lives in a rural area
Victim Services
Accessibility (Also check on below
Disability Access (Hearing/Physical/Mental)
Immigrant Access
Language Access
Collaboration
Coordinated Community Response
Safety Planning
Technology and Safety
Program Development
Board Development
Curricula and Training development
Data Collection
Developing/Sustaining Diverse/Underserved
Programs
Develop enhanced CLSSP Services
FJCs/Co-located Programs
Grant Administration
Grant Guidelines
Program Development (DV/SA/Stalking)
Program Evaluation
Protocol/Policy Development
Standards of Service (DV/SA/Stalking)
Strategic Planning
Technology Capability
Victim Service Administration and Operation
Ethnicity
African-American
African (Foreign born)
Arab/Middle-eastern
Asian
Caucasian
Hispanic/Latino
Native American
Native Hawaiian or Pacific Islander
Other
Specific Details (if filling
out hard copy, attach
details on a separate piece
of paper)
1101 14th Street, NW Suite 300 Washington, DC 20005 Tel 2
202-326-0040 Fax 202-589-0511 www.legalmomentum.org