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 Name
Last Name
Client Date of Birth
-
Month
-
Day
Year
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.
*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
City
State / 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 Name
Last Name
Date of birth of person who used violence
-
Month
-
Day
Year
Date
CPS Caseworker Name
First Name
Last Name
CPS Caseworker Email
example@example.com
CPS Caseworker Phone Number
Please enter a valid phone number.
CPS Caseworker's Current Supervisor:
First Name
Last Name
What stage of service is the CPS case in?
Please Select
Investigations
Alternative Response
Family based Safety Services
Conservatorship
Has the client expressed interest in any of these services? These services are voluntary and CANNOT be mandatory.
Group Counseling
Individual Counseling
Play/Child/Adolescent Therapy
Advocacy (protective order assistance, legal assistance, CPS case management, Crime Victim's Compensation, relocation, thrift store, food pantry, court accompaniment, post-removal crisis intervention.)
Other
None of the Above
Client Case Victimization History
Is the Department primarily involved with this family due to domestic violence?
Please Select
Yes
No
Has the client self-identified as a CURRENT victim of domestic violence?
Please Select
Yes
No
Has the client self-identified as a PAST victim of domestic violence?
Please Select
Yes
No
I have reason to believe the client is a victim of domestic violence due to:
Concerns collaterals have reported
Arrests/charges for domestic violence
Behavior that caseworker has witnessed is indicative of domestic violence
Outcries the children have made
Law enforcement calls to the home
Client self-identified as a victim of domestic vioelnce
Other
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?
Please Select
Yes
No
Do you have immediate safety concerns for this client?
Please Select
Yes
No
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)
Please Select
Yes
No
Relationship status with the abuser. (Check all that apply)
Married
Divorced
Cohabitating
Separated
Separated but considering reconciliation
Dating
Ex-dating partner
Abuser is in jail/prison
other
Is the client's abuser the father to any of the children involved in this case?
Please Select
Yes
No
I have observed the following protective factors in the client (adult victim). Check all that apply
Separation from the abuser
Teaching child to contact 911
Comforts child/Emotional bond
Tells child not to intervene
Believes child's report of maltreatment
Support from friends and family
Appeases abuser to deescalate abuse
Does not place responsibility for violence on child
Understands that her safety and child's safety are linked
Understands that exposure to abusive behavior is unhealthy for their child
Sends child to another room, a neighbor's home, etc. when anticipating abuse or when abuse starts
Utilized services to help with basic needs(i.e. police, courts, shelter services, DV safety planning)
Has demonstrated problem solving skills as demonstrated by past actions
Articulates plan for child safety (i.e. leaving when situation escalates, calling police if protective order is violated, etc.)
Other
None 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 abuse
Physical Abuse
Use of a weapon
Stalking
Damaging property
Financial Control
Coercion
Isolation from friends/family
Intimidation
Rape
Threats of harm to self, children, client
Strangulation
Client has had to seek medical attention for injuries
Client reports that he/she feels unsafe or afraid
Threats to flee with or hide the child/children
Other
Protective Order
Does this client currently have a protective order?
Please Select
Yes
No
Has your client applied for a protective order?
Please Select
Yes
No
Has your client verbalized interest in seeking a protective order?
Please Select
Yes
No
Other Victimization History
Has the client had previous involvement with The Department due to domestic violence?
Please Select
Yes, with this partner
Yes, with a previous partner
No prior involvement
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 Select
Yes
No
Please upload all pertinent files here (Child Safety Plan, Domestic Violence Safety Plan, etc.)
Browse Files
Drag and drop files here
Choose a file
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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
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