CPS ADVANCE Referral Form
THIS FORM IS INTENDED
FOR CPI AND CPS CASEWORKER/SUPERVISOR USE
For the purpose of this referral,
is defined as a
of behaviors one parent
over the victimized parent.
Please fill the form out in its entirety. If there is a question that does not apply to your Client, write N/A.
Client Date of Birth
Any past names used (maiden name, etc.):
Current City of Residence:
Full name of Child or Children and their DOB
Primary Language Spoken:
Please note, when providing DCFOF 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 DCFOF employee to identify.
Safe Phone Number for Client (if one exists):
Safe Email for Client (if one exists):
Does this client need any accommodations to access services? Consider things like learning disabilities, deafness, etc.
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)
Date of birth of person who used violence
CPS Caseworker Name:
CPS Caseworker Email:
CPS Caseworker Phone Number:
CPS Caseworker's Current Supervisor:
What stage of service is the CPS case in?
Family Based Safety Services
Is the referred parent required to participate in ADVANCE as part of their CPS case or a court order?
You may not know the answer to this right now if you are CPI, but given your expertise and if you had to make a best guess, do you anticipate this case being referred to FBSS?
I Don't Know
Has the client expressed interest in any of these services? These services are voluntary and CANNOT be mandatory:
Advocacy (protective order assistance, legal assistance, CPS case management, Crime Victim's Compensation, relocation, thrift store, food pantry, court accompaniment, post-removal crisis internvention)
None of the above
Is the Department primarily involved with this family due to domestic violence?
If the Department's primary involvement is NOT due to domestic violence, however domestic violence is a concern, what is the reason for primary involvement?
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 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 violence
If Other, please explain:
Please provide detailed information about the violence used against the referred parent here
Is one of your concerns in this case about substance use?
What are the substance use concerns for this case? (Who is using what?)
Is one of your concerns in this case about mental health?
What are the mental health concerns for this case? (Who is struggling with what?)
If you have NOT checked any of the above boxes this client is NOT appropriate for services, including the ADVANCE program.
Has the client been a victim of physical violence within an intimate relationship in the last 60 days?
If no, when was the last physically violent incident?
Do you have immediate safety concerns for this client?
If you are concerned this client is not safe, please call the DCFOF Crisis Line at 940-382-7273 or notify Sarah Lehman at 940-387-5131 x258 or Slehman@dcfof.org
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)?
If No, please explain why a Domestic Violence Safety Plan has not been completed:
Relationship status with the abuser check all that apply)
Separated but considering reconciliation
Abuser is in jail/prison
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 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
Utilizes 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.)
None of the above
If Other, please explain:
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):
Use of a weapon (includes hands/fists)
Isolation from friends/family
Threats of harm to self, children, client
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
If Other, please explain:
Does this client currently have a protective order?
If Yes, check the type of protective order this client currently has.
Emergency Protective Order/Magistrate's Order of Emergency Protection (31, 61, or 91 Days)
Temporary Ex Parte Protective Order (14-20 Days)
Final Protective Order (2 or more years)
If the client has a Emergency Protective Order/Magistrate's Order of Emergency Protection (31, 61, or 91 Days), what is the expiration date?
If the client has a Temporary Ex Parte Protective Order, when is their hearing to request a Final Protective Order?
If the client has a Final Protective Order, what is the expiration date?
If the client does not have a protective order, have you discussed seeking a protective order with this client?
Has your client applied for a protective order?
Has your client verbalized interest in seeking a protective order?
Other Victimization History
Has this client had previous involvement with The Department due to domestic violence?
Yes, with this partner
Yes, with a previous partner
No prior involvement
Regardless of their current relationship with the referred parent, their relationship with the children, their geographic location, etc. the fact that someone has used violence against a current or former partner makes them a risk to the referred parent, the referred parent’s children, and others in the community. When these people who have used violence are not referred to a BIPP program, the danger they pose to others has not been properly addressed. There are limited situations where it would be appropriate to not immediately refer someone to BIPP, such as, the person using violence first needs to address a substance abuse issue, they are incarcerated and their prison doesn’t offer BIPP, they have been deported to a country where BIPP is not available, or referral to BIPP would cause a dangerous escalation of violence.
Once you get in contact with this client's abuser, do you plan to refer this person to BIPP ( Please not that the person who used violence should be referred- not necessarily with a 2054- to a BIPP program)?
If no, please explain:
If so, which BIPP Program will you be referring to?
If other, which program?
Per the SDM tool, what are the current danger indicators and/or risk factors The Department has identified regarding this client and the family?
Please upload all pertinent files here (Child Safety Plan, Domestic Violence Safety Plan, etc.)
What else do you want us to know?
Please not that Child Safety Plans, Domestic Violence Safety Plans, Parental Child Safety Placement tools, and/or Removal Affidavits
to be sent with this referral form. DCFOF Cannot accurately assess the client's current situation, active safety threats, and The Department's concerns, without 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 DCFOF IN ORDER FOR YOUR CLIENT TO RECEIVE SERVICES.
Thank you! If you have any questions about this referral, please email Sarah Lehman at firstname.lastname@example.org.