ADVANCE Referral Form- Final

Form
Please fill the form out in its entirety. If there is a question that does not apply to this client, write N/A.
Client Name

First NameLast Name
Client Date of Birth

MonthDayYear
Date
Any past names used (maiden name, etc.):
Full name of Child or Children and their DOB:
Primary Language Spoken
Safe Phone Number for Client (if one exists):
Please enter a valid phone number.Format: (000) 000-0000.
*Please note, when providing SPFVS with a "safe number" that means that you have spoken with this client, verified that it is a safe number, verified that it is safe to leave a voicemail, and verified that it is safe for a SPFVS employee to identify.
Safe Email for Client (if one exists):
example@example.com
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of person who used violence against referred parent (Please note that the person who used violence should be referred-not necessarily with a 2054- to a BIPP program)

First NameLast Name
Date of birth of person who used violence

MonthDayYear
Date
CPS Caseworker Name

First NameLast Name
CPS Caseworker Email
example@example.com
CPS Caseworker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
CPS Caseworker's Current Supervisor:

First NameLast Name
What stage of service is the CPS case in?
Has the client expressed interest in any of these services? These services are voluntary and CANNOT be mandatory.

Group CounselingIndividual CounselingPlay/Child/Adolescent TherapyAdvocacy (protective order assistance, legal assistance, CPS case management, Crime Victim's Compensation, relocation, thrift store, food pantry, court accompaniment, post-removal crisis intervention.)OtherNone of the Above
Client Case Victimization History
Is the Department primarily involved with this family due to domestic violence?
Has the client self-identified as a CURRENT victim of domestic violence?
Has the client self-identified as a PAST victim of domestic violence?
I have reason to believe the client is a victim of domestic violence due to:

Concerns collaterals have reportedArrests/charges for domestic violenceBehavior that caseworker has witnessed is indicative of domestic violenceOutcries the children have madeLaw enforcement calls to the homeClient self-identified as a victim of domestic vioelnceOther
Please provide detailed information about the violence used against the referred parent here:
If you have NOT checked any of the above boxes this client is NOT appropriate for services, including the ADVANCE program.
Immediate Safety
Has the client been a victim of physical violence within an intimate relationship in the last 60 days?
Do you have immediate safety concerns for this client?
If you are concerned this client is not safe, please call the Safer Path 24- hour hotline @ 830-569-2001. IMMEDIATELY, and DO NOT rely on this referral as a means to create immediate safety for your client.
Have you completed a Domestic Violence Safety Plan with this client (NOT A CHILD SAFETY PLAN)
Relationship status with the abuser. (Check all that apply)

MarriedDivorcedCohabitatingSeparatedSeparated but considering reconciliationDatingEx-dating partnerAbuser is in jail/prisonother
Is the client's abuser the father to any of the children involved in this case?
I have observed the following protective factors in the client (adult victim). Check all that apply

Separation from the abuserTeaching child to contact 911Comforts child/Emotional bondTells child not to interveneBelieves child's report of maltreatmentSupport from friends and familyAppeases abuser to deescalate abuseDoes not place responsibility for violence on childUnderstands that her safety and child's safety are linkedUnderstands that exposure to abusive behavior is unhealthy for their childSends child to another room, a neighbor's home, etc. when anticipating abuse or when abuse startsUtilized services to help with basic needs(i.e. police, courts, shelter services, DV safety planning)Has demonstrated problem solving skills as demonstrated by past actionsArticulates plan for child safety (i.e. leaving when situation escalates, calling police if protective order is violated, etc.)OtherNone of the above
What restrictions has The Department put in place to ensure child safety plan(Safety Plan/PCSP) and what are the terms of those restrictions?
The Client has been a victim of the following in the current/most recent intimate relationship (check all that apply):

Emotional/Verbal abusePhysical AbuseUse of a weaponStalkingDamaging propertyFinancial ControlCoercionIsolation from friends/familyIntimidationRapeThreats of harm to self, children, clientStrangulationClient has had to seek medical attention for injuriesClient reports that he/she feels unsafe or afraidThreats to flee with or hide the child/childrenOther
Protective Order
Does this client currently have a protective order?
Has your client applied for a protective order?
Has your client verbalized interest in seeking a protective order?
Other Victimization History
Has the client had previous involvement with The Department due to domestic violence?
Once you get in contact with this client's abuser, do you plan to refer this person to BIPP (Please note that the person who used violence should be referred- not necessarily with a 2054- to a BIPP program)?
Please upload all pertinent files here (Child Safety Plan, Domestic Violence Safety Plan, etc.)

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What else do you want us to know?
Please note that Child Safety Plans, Domestic Violence Safety Plans, Parental Child Safety Placement tools, and/or Removal Affidavits ARE REQUIRED to be sent with this referral form. SPFVS cannot accurately assess the client's current situation, active safety threats, and The Department's concerns, with out having these documents and being as informed as possible of the totality of the client's circumstances.
BY SUBMITTING THIS FORM YOU ARE CERTIFYING THAT YOU HAVE ATTACHED ALL REQUESTED AND PERTINENT PAPERWORK PERTAINING TO THIS CLIENT AS REQUESTED BY SPFVS IN ORDER FOR YOUR CLIENT TO RECEIVE SERVICES.
Thank You! If you have any questions about this referral, please email education@saferpathfvs.org
Should be Empty:

Form

Please fill the form out in its entirety. If there is a question that does not apply to this client, write N/A.

*Please note, when providing SPFVS with a "safe number" that means that you have spoken with this client, verified that it is a safe number, verified that it is safe to leave a voicemail, and verified that it is safe for a SPFVS employee to identify.

Client Case Victimization History

If you have NOT checked any of the above boxes this client is NOT appropriate for services, including the ADVANCE program.

Immediate Safety

If you are concerned this client is not safe, please call the Safer Path 24- hour hotline @ 830-569-2001. IMMEDIATELY, and DO NOT rely on this referral as a means to create immediate safety for your client.

Protective Order

Other Victimization History

BY SUBMITTING THIS FORM YOU ARE CERTIFYING THAT YOU HAVE ATTACHED ALL REQUESTED AND PERTINENT PAPERWORK PERTAINING TO THIS CLIENT AS REQUESTED BY SPFVS IN ORDER FOR YOUR CLIENT TO RECEIVE SERVICES.

Thank You! If you have any questions about this referral, please email education@saferpathfvs.org