DCFOF ADVANCE Referral

THIS FORM IS INTENDED ONLY FOR CPI AND CPS CASEWORKER/SUPERVISOR USE

For the purpose of this referral, Domestic Violence is defined as a pattern of behaviors one parent intentionally uses to gain and maintain power and control 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 (Victimized Parent) Contact Information

Accurate and complete Client information is essential for DCFOF ADVANCE staff to safely connect with Clients you refer and keep accurate records.

Client First Name:

Client Last Name:

Any past names used (maiden name, etc.):

Client's Date of Birth:

Client's Primary Language:

What Other Language?:

Client's Current City of Residence:

Safe Phone Number for Client (if one exists) Use (###) ###—#### format so you can copy and paste from IMPACT:

A "safe number" means that you have spoken with this Client and VERIFIED that it is safe to leave a voicemail and for a DCFOF employee to identify themselves in a message.

I've checked and verified it's safe.

DCFOF ADVANCE staff contact referred parents using a Blocked or Unknown number unless CPI/CPS staff provide information to confirm it is safe to call from DCFOF's main office number.

I have or will remind this Client that they should expect a call from a Blocked or Unknown number within 2 business days of submitting this referral OR I will be providing more information about special accommodations this Client needs to access services below.

Safe Email for Client: If you do not have this Client's email, please ask the Client to provide their email address BEFORE submitting this referral. If this Client doesn't have an email address or does not know how to use email, please check the box below and include details in the question below about needed Client accommodations.

This Client does not have an email address or does not know how to use email.

Does this Client need any accommodations to access in-person or virtual/online services? Consider things like learning disabilities, deafness, lack of transportation, lack of internet or device with video conferencing capabilities, technology literacy, etc.

YesNo

What accommodations does this Client need to access services?:

Family and Relationships

Information about a Client’s children and the Person Using Domestic Violence [PUDV] helps DCFOF ADVANCE staff confirm eligibility of referral, gauge safety concerns, and identify appropriate resources for the referred Client.

How many children does the Client have?:

Child's First and Last Name:

Child's Date of Birth:

Child's First and Last Name:

Child's Date of Birth:

Child's First and Last Name:

Child's Date of Birth:

Child's First and Last Name:

Child's Date of Birth:

Child's First and Last Name:

Child's Date of Birth:

Child's First and Last Name:

Child's Date of Birth:

Child's First and Last Name:

Child's Date of Birth:

Child's First and Last Name:

Child's Date of Birth:

First and Last Name of Person who Used Domestic Violence (PUDV) against referred Client (victimized parent). Please note that the Alleged Perpetrator (AP) in your CPI case may not always match the PUDV that you list here. The PUDV should be identified using the TDFPS Domestic Violence Resource Guide (p. 1-2) definition of Domestic Violence and Coercive Control.

PUDV's First Name

PUDV's Last Name

PUDV's Date of Birth:

Is the PUDV a parent to any of the children involved in this case?

Yes, they are a biological parentYes, but they are not a biological parentNo

Which child or children are biologically related?

Client's Relationship Status with PUDV:

Where did the PUDV live before your case opened? Include last known locations of the PUDV

Where does the PUDV currently live now that your case is open?:

Where is the PUDV temporarily living due to a CPS Safety Plan or Emergency Protective Order?:

Protective Orders

Does this Client currently have a protective order?:

YesNo

If Yes, check the type of protective order this Client currently has.:

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?:

YesNo

Has your Client applied for a protective order?:

Has your Client verbalized interest in seeking a protective order?:

Other Referral Information

What else do you want us to know?:

While parents with open CPI/CPS cases may seek additional and voluntary DCFOF assistance/supports on their own, this form must be completed BEFORE a parent can begin the free ADVANCE class.

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 YOU TO REFER FOR CLIENT.

Contact Information