LAW ENFORCEMENT REFERRAL FORM

Thank you for your referral. Please inform the victim that when a staff member reaches out to them from DCFOF, it will appear as an unknown call. If this is a crisis situation or the victim needs immediate assistance, please call our 24/7 Crisis Line at 940-382-7273.

URGENT? (Requires response within 24 hours?)

YesNo

High-Lethality?

YesNo

Domestic Violence (DV) or Sexual Assault (SA) offense?

DVSA

Date of Crime

Law Enforcement Agency

Referring Officer:

Referring Officer's email:

Officer Phone Number:

Case/Report Number:

Victim Name:

Victim's DOB:

If victim is a minor, please share name and contact information of parent or guardian currently participating in the case if applicable:

Victim's Primary Language

Victim's Safe Phone Number:

Victim's safe email:

Is the victim currently residing with the suspect?:

Suspect's Name:

Suspect's DOB:

Suspect's Relationship to Victim

Was an arrest made?

YesNo

If no arrest, is there an active warrant?

YesNo

Did the victim receive medical attention? (EMS or hospital)

YesNo

SAFETY CONCERNS:

BRIEF NARRATIVE OF CRIME:

Upload Offense Report:

Upload Lethality Assessment if applicable:

Has a CPS Report been made?

YesNoUnknown

If so, please provide known information:

Upload CPS report:

Has an EPO been issued?

YesNoRequestedUnknown

If so, please provide known information:

Upload EPO: