CPS BIPP Referral Form

THIS FORM IS INTENDED FOR CHILD PROTECTIVE SERVICES USE ONLY. 
If you need help, set up an intake appointment to speak with an advocate by calling our Outreach Office at 940-387-5131. If this is a crisis and you need to speak with someone right away, call our 24-Hour Crisis Line at 940-382-7273 or 800-572-4031.

Although clients with open CPS cases may seek DCFOF services on their own, this form must be received prior to an appointment for referred clients to receive services.


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

Referral Information














Client Case
Reason for Referral

If you are uncertain what services would benefit your client most, please consult David Almager at 940-387-5131 x238.







If you have NOT checked any of the above boxes this client is NOT appropriate for BIPP Services.
Immediate Safety Concerns for Victim(s)







Protective Order






Other Victimization History






Please not 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. 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 David Almager at 940-387-5131 x238.