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 and Last Name:
Any past names used (maiden name, etc.):
Client's Date of Birth:
Client's Primary Language:
Please select...
English
Spanish
Other
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 include details in the question below about needed Client
accommodations.
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.
Please select...
Yes
No
What accommodations does this Client need to access services?:
Anticipated Outcomes
What do you expect as a result of submitting this referral? What does your Client expect?
Is the Client
required
to participate in ADVANCE as part of their TDFPS case or a court order?:
Please select...
Yes
No, it's recommended but voluntary
Please upload a copy of the CPS Family Plan or the Temporary Order that states ADVANCE is the Domestic Violence victim intervention for the Client.:
What do you hope the Client will get out of this referral? (
Check all that apply
):
Awareness of available free ADVANCE class and additional assistance/supports beyond the free ADVANCE class
Completion of the free ADVANCE class
Knowledge of Domestic Violence perpetrator dynamics, definitions, and statistics
Knowledge of how to parent a child who has been impacted by a Domestic Violence perpetrator
Knowledge of how to Parallel Parent safely with a Domestic Violence Perpetrator (since traditional Co-Parenting collaboration is not safe or possible)
Knowledge of how to create healthy boundaries
Increased self esteem
Knowledge of how violence is minimized, normalized, and learned in our society
Knowledge of possible civil and legal remedies
Other
If Other, please explain:
Has the Client expressed interest in any of these additional free supports/assistance available beyond the free ADVANCE class?
These supports/assistance are
voluntary
and
CANNOT
be required by TDFPS
.:
Adult Counseling
Play/Child/Adolescent Therapy
Advocacy (protective order assistance, legal information and referral, CPS case management, Crime Victims' Compensation, relocation, thrift store, food pantry, court accompaniment, post-removal crisis intervention)
Emergency Shelter
None of the above
Please call the DCFOF 24/7 Crisis Line
940-382-7273
to talk to Crisis Line staff about immediate options for Emergency Shelter for this Client and their family.
Please check this box to confirm you understand that best practice involves you helping your Client call the DCFOF 24/7 Crisis Line to ask for Emergency Shelter options.
In order for DCFOF ADVANCE staff to provide updates about ADVANCE referral status, the referred Client will have to sign a time-limited (90 day max) DCFOF Release of Information form with a DCFOF staff member.
I have or will remind this Client that they will need to sign a DCFOF Release of Information form in order for CPI/CPS staff to get confirmation of contact or participation information.
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?:
Please select...
1
2
3
4
5
6
7
8
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 Date of Birth:
Is the PUDV a parent to any of the children involved in this case?
Please select...
Yes, they are a biological parent
Yes, but they are not a biological parent
No
Client's Relationship Status with PUDV:
Please select...
Married
Divorced
In Active Divorce Litigation
Dating and Living Together but Not Married
Dating
Ex-Dating Partner
Widowed/PUV is Deceased
Where did the PUDV live
before
your case opened?
Include last known locations of the PUDV
Please select...
with the victimized parent
in their own home without the victimized parent
with their family/friends
motel/hotel
homeless
county jail
prison
PUDV is deceased
Where does the PUDV
currently
live now that your case is
open
?:
Please select...
temporarily separated by CPS/police through CPS Safety Plan or Emergency Protective Order
working with a Special Investigator to locate PUDV
with the victimized parent
in their own home without the victimized parent
with their family/friends
motel/hotel
homeless
county jail
prison
unable to locate with the help of a Special Investigator
PUDV is deceased
Where is the PUDV temporarily living due to a CPS Safety Plan or Emergency Protective Order?:
Please select...
with the victimized parent
in their own home without the victimized parent
with their family/friends
motel/hotel
homeless
county jail
prison
CPI/CPS Case Information
Information about the case lets us know if there are other concerns we should look out for, as well as, how we can approach the Client in order to have the best chance of successful connection.
When was the TDFPS case opened?:
Caseworker First and Last Name:
Caseworker Phone Number:
Caseworker Email:
Caseworker's Current Supervisor:
What stage of service is the CPI/CPS case in?:
Please select...
Investigations
Alternative Response
Family Based Safety Services
Conservatorship
You may not know the answer to this right now, but given your expertise and if you had to make a best guess, do you anticipate this case being referred to FBSS?:
Please select...
Yes
No
I Don't Know
Do you have any name or contact information regarding the CASA assigned to this case?:
Please select...
Yes
No
What is the CASA worker's name, phone number, and email address?
Per the SDM tool, what are the current danger indicators and/or risk factors TDFPS has identified regarding this family?:
The PUDV has used the following pattern of abusive behaviors against this Client (
check all that apply
):
Emotion/Verbal abuse (
GASLIGHTING
/put downs/name calling/guilting/humiliation)
Isolation from friends/family
Financial Control
Preventing Client from leaving
Damaging property
Extreme jealousy
Threats to flee with or hide the child/children
Threats by PUDV to self-harm or kill themselves
Threats to harm Client or children
Aggression towards intervenors (police/CPS/bystanders/etc.)
Threats to harm others such as friends, family, co-workers, or a new partner
Abusing pets or animals
Threats to kill Client or child/children
Rape/"forced or pressured sex"
Holding Client Hostage/Restraining Client
Pushing/shoving
Kicking
Hitting/slapping/backhanding
Attacking Client with an object or weapon (i.e. knife, gun, etc.)
Physical violence during pregnancy
STRANGULATION
/choking/grabbing Client's neck/suffocating
Other
If Other, please explain:
The behaviors selected indicate that the PUDV is at an increased risk of killing the Client.
Learn how you can
address urgent safety concerns here
and learn about
caseworker safety here
.
If you have urgent concerns for the Client's safety, please email Sarah Lehman at Slehman@dcfof.org after completing this referral to discuss options to expedite referral.
Is TDFPS primarily involved with this family due to concerns of a Domestic Violence perpetrator?:
Please select...
Yes
Yes, and other intersecting issues (i.e. substance use, mental health, etc.)
No
If TDFPS' primary involvement is NOT due to a Domestic Violence perpetrator's behavior, even though a Domestic Violence perpetrator's behavior is now a concern, what is the reason for primary involvement?:
Please share more about the pattern of Domestic Violence perpetrator behaviors the PUDV used that caused TDFPS to get involved.
You can also include details of how the victimized parent reacted/responded to PUDV's abuse.
Has TDFPS had previous case history with this family due to concerns about a Domestic Violence perpetrator?:
Please select...
Yes, with this case's PUDV
Yes, with a previous partner
No prior involvement
Is one of your concerns in this case about substance use?:
Please select...
Yes
No
What are the substance use concerns for this case? (Who is using what?):
Is one of your concerns in this case about mental health?:
Please select...
Yes
No
What are the mental health concerns for this case? (Who is struggling with what?):
Has the Client self-identified they are CURRENTLY experiencing Domestic Violence (including experiencing emotional/verbal/sexual/physically abusive behaviors from PUDV)?:
Please select...
Yes
No
Has the Client self-identified they experienced Domestic Violence in the PAST?:
Please select...
Yes
No
How long ago and from whom?:
I have reason to believe the Client is a victim of Domestic Violence due to
:
Client self-identified as a victim of Domestic Violence
Outcries the children have made
Concerns collaterals have reported
Law enforcement calls to the home
Arrest(s) for physical violence, sexual violence, and/or harassment/stalking
Charge(s) for physical violence, sexual violence, and/or harassment/stalking
Behavior that caseworker has witnessed is indicative of Domestic Violence
Other
What did the child(ren) outcry?:
What concerns did collaterals report?:
Which law enforcement agency or agencies did calls of service to the home?:
Which law enforcement agency or agencies made arrests to whom and for what?:
If you have any calls of service or police reports, please upload those here:
Which prosecutor's office(s) filed charges against whom and for what?:
What behavior did you witness that is indicative of Domestic Violence?:
If Other, please explain:
I believe or have identified that the PUDV's abusive behavior has impacted the children in these ways (
Learn more at the
Safe and Together Institute
about
multiple pathways to harm
):
Deprivation of Basic Needs
: Does not financially contribute for child's basic necessities, Stops paying rent and/or utilities if removed from the house by CPS/police/court order, withholds child support or dictates how protective/victimized parent can spend payments, sabotages protective/victimized parent's housing/vehicle/job/etc., Sabotages or denies child's relationships with others, Denies child's access to supportive services
Academic
: Declining school performance, Absenteeism/Truancy
Behavioral
: Bedwetting, Sleep issues, Withdrawn/passive, Disobedient/defiant, Fighting/hurting other children, Substance use, Running away, Self-harm, Stealing, Hurting animals
Cognitive
: Believes anger = someone getting hurt, Concentration and memory problems, Violence is normalized
Developmental
: Minimal/delayed speech or muteness, Motor development delayed, Born with medical conditions, Regression
Emotional
: Anger/irritability, Anxiety/panic/nervousness, Depression/sadness, Embarrassment/shame, Fear of abuse/retaliation by PUDV, Guilt/self-blame, Suicidal ideation or attempts
Physical
: Physical or sexual abuse by PUDV, Born prematurely, Eating problems/ disorders, Failure to thrive, Poor personal hygiene , Psychosomatic complaints like headaches, stomachaches
Social
: Shows anger towards victim parent for PUDV’s abuse, Bullying, Destruction of property, Embarrassed by family, Using or experiencing abuse in dating relationship, Isolated/lonely, Lack of social skills, Parentification, Poor problem-solving skills
Drawn into Violence
: Seeing/Hearing violence, Getting injured while intervening, Being interrogated or used as a “spy” by PUDV, Being restricted from contact with others, Being removed from non-violent parent, Having to call police/ others for help, Being coerced or forced by PUDV to participate in abuse, Attempting to/killing the abuser
Addressing Domestic Violence Perpetrator Related Dangers
In order to best serve our Clients, it's important for us to be aware of what has already been done or will be done to address the dangers related to the Domestic Violence perpetrator's behaviors.
Do you have immediate concerns for this Client's physical safety?:
Please select...
Yes
No
Please call the DCFOF 24/7 Crisis Line
940-382-7273
to talk to Crisis Line staff about immediate options for physical safety for this Client and their family.
Please check this box to confirm that you understand that submitting a referral is not a means to create immediate safety for your Client.
In what ways has TDFPS intervened or will intervene to address the safety concerns created by the PUDV?
Do you plan to refer PUDV to a Battering Intervention and Prevention Program (BIPP)?:
Please select...
Yes, with a 2054 AND it's required/court ordered
Yes, with a 2054 BUT it's voluntary to complete
Yes, without a 2054 AND it's required/court ordered
Yes, without a 2054 BUT it's voluntary to complete
No
No, because the PUDV is not a legal adult/they are an adolescent and we will submit a referral to DCFOF's Adolescent Non-Violence Program (ANVP)
If so, which BIPP Program will you be referring to?:
Please select...
DCFOF
First Steps
Dallas Sigma
Other
I acknowledge BIPP is recognized as the
only
effective treatment for Domestic Violence perpetrators and victims of Domestic Violence cannot stop the abuse on their own.
Please check this box to confirm you understand (without opportunity for appropriate intervention like a referral to BIPP) if the PUDV will continue to have any access to the children, then the PUDV may use the children to further abuse the Client or
may abuse the children themselves
in the future.
Separation does not equal safety
for the Client or their children per the
TDFPS Domestic Violence Resource Guide: p. 19
.
Why has TDFPS decided not to refer the PUDV to BIPP?:
Please select...
PUDV is deceased
PUDV cannot be tracked or located
PUDV is incarcerated in Prison/City or County Jail
PUDV refused to cooperate
PUDV is not the biological parent to the children
PUDV is not involved in the case
PUDV is separated from victimized parent and they no longer live together
PUDV lives in a different state/country
PUDV has current mental health issues or illness
PUDV has current substance abuse
Please refer the PUDV to BIPP per the
TDFPS Domestic Violence Resource Guide
:
p. 19.
Did you know the
National Domestic Violence Hotline
can help you locate BIPP in another state?
Did you know DCFOF BIPP staff can help to engage the PUDV if you submit a
BIPP referral
?
Documentation of attempted interventions are also important for TDFPS case history.
Once our BIPP staff receive your referral, they can attempt contact to provide more details about BIPP to the PUDV and see if they are interested in getting started.
Please refer the PUDV to BIPP once they are released from incarceration per the
TDFPS Domestic Violence Resource Guide
:
p. 19. You can register to receive free notifications about a PUDV's incarceration status with the help of
Texas VINE
(Victim Information & Notification Everyday).
Please save the
BIPP referral link
for future use.
Please refer the PUDV to BIPP once substance use treatment is completed per the
TDFPS Domestic Violence Resource Guide
:
p. 19.
Substance abuse is
NOT
a cause of Domestic Violence but influences the likelihood of future successful behavioral changes.
Please save the
BIPP referral link
for future use.
If the PUDV's controlling/violent behavior is truly caused by mental illness, then this is not an appropriate referral to our ADVANCE class.
Please email Sarah Lehman at Slehman@dcfof.org for more information and to consult about appropriate referral options.
Have you talked with the Client and created a Domestic Violence Safety Plan with them?
Consult the
TDFPS Domestic Violence Resource Guide
(p. 10-14; 18
)
:
Please select...
Yes
No
Have you implemented a CPS Safety Plan and/or PCSP that addresses the PUDV's use of Domestic Violence?:
Please select...
Yes
No
Please upload a copy of the CPS Safety Plan and/or PCSP here.
Have the children been legally removed due to concerns created by the Domestic Violence perpetrator?:
Please select...
Yes
Yes, and other intersecting issues (i.e. substance use, mental health, etc.)
No
Please upload a copy of the CPS removal affidavit(s) here.
Please upload a copy of the CPS Temporary Orders and/or Family Plan of Service here.
I have observed the following protective factors in the Client (
Check all that apply
):
Comforts child/
Emotional bond
(
Creating A Context For Children's Healing p.4-5)
Support from friends and family
Tells child not to intervene
Sends child to another room, a neighbor's home, etc. when anticipating abuse or when abuse starts
Believes child's report of maltreatment
Does not place responsibility for PUDV's behavior/violence on child
Educates child about types of maltreatment, abuse, and/or Coercive Control
Teaching child to contact 911
Appeases PUDV to deescalate abuse
Used self defense
Understands that her safety and child's safety are linked
Understands that exposure to abusive behavior is unhealthy for their child
Utilizes services to help with basic needs (i.e. police, courts, outreach/shelter services, Domestic Violence safety planning)
Has demonstrated problem solving skills as demonstrated by past actions
Sacrifices their needs for child's needs (i.e. food, clothing, providing child a bedroom, etc.)
Articulates plan for child safety (i.e. leaving when situation escalates, calling police if protective order is violated, etc.)
Other
None of the above
If Other, please explain:
Protective Orders
Does this Client currently have a protective order?:
Please select...
Yes
No
If Yes, check the type of protective order this Client currently has.:
Please select...
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?:
Please select...
Yes
No
Has your Client applied for a protective order?:
Please select...
Yes, with the help of a free District Attorney's Protective Order Unit (Denton, Dallas, Collin, Tarrant, etc.)
Yes, with the help of a private attorney they retained
Yes, with the help of a free Legal Aid of Northwest Texas staff attorney
Yes, with the help of a free DCFOF staff attorney
Yes, with other help not listed
Yes, with no help and they filed Pro Se (no attorney)
No
Has your Client verbalized interest in seeking a protective order?:
Please select...
Yes
No
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