Project Safe: Abuse Intervention Services (IPAEP or GVIP)

Today's Date*

MonthDayYear
Date
Referral Name*

First NameLast Name
Referral Date of Birth*

MonthDayYear
Date
Referral Address (please put N/A if no permanent address)*

Street Address

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CityState / Province

Postal / Zip Code
Referral Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Referral Email Address*
ProbationDCFSelf
Probation Officer Name*
Court*
Court if Other was selected*
Referral Charge(s)*
Disposition*
Caseworker Name*
DCF Office*
DCF Office if Other was selected*

Intimate Partner Abuse Education Program (IPAEP)
1. Individual Intake Evaluation
2. Minimum of 40 weeks (80 hours) of structured groups focusing on the prevention and intervention of power and control behaviors used in intimate relationships and the effects of those actions.
Generalized Violence Intervention Program (GVIP)
1. Individual Intake Evaluation
2. Minimum of 15 weeks (22.5 hours) of structured groups focusing on the prevention and intervention of generalized violence, inappropriate anger expression, and related behaviors.
Intimate Partner Abuse Education Program (IPAEP)Generalized Violence Intervention Program (GVIP)Adolescent Intimate Partner Abuse Education Program (IPAEP)Adolescent Generalized Violence Intervention Program (GVIP)
YesNo
If yes, which program(s)*
Intake fee: $130 Weekly session fee based on sliding scale: $15-75

BSCS will negotiate a payment schedule with any participant declared indigent for the intake appointment, they will be required to pay a nominal fee of $15 per session and/or complete service.

Abuse Intervention Services will reach out to the Court and/or DCF to collect the necessary documents.
The above-named referral has been instructed to call BSCS at 617-471-8400 to set up an appointment for intake by the following date: Date* . Failure to schedule, attend, or complete an intake will result in notification to Court and/or DCF.
ProbationDCFSelf
If you have any questions when submitting this referral form, please contact Projectsafe@baystatecs.org or 617-471-8400 x 129.
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