CPS Adolescent Non-Violence Program Referral Form
THIS FORM IS INTENDED FOR CHILD PROTECTIVE SERVICES USE ONLY.
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
Minor Client Name:
Minor Client Date of Birth
Primary Language Spoken:
Please select...
English
Spanish
Other
What Other Language?:
Parent/Guardian Name:
Parent/Guardian Primary Language Spoken:
Please select...
English
Spanish
Other
What Other Language?:
Parent/Guardian Phone Number:
Parent/Guardian Email:
When was the TDFPS case opened?:
Caseworker Name:
Caseworker Email:
Caseworker Phone Number:
Caseworker's Current Supervisor:
What stage of service is the CPS case in?
Please select...
Investigations
Alternative Response
Family Based Safety Services
Conservatorship
Client Case
Reason for Referral
All Adolescent groups and individual sessions will be done in person and free of charge.
Is the Department primarily involved with this family due to Domestic/Family Violence?
Please select...
Yes
No
If the Department's primary involvement is NOT due to Domestic/Family Violence, but there is a concern about violence and aggression, what is the reason for primary involvement?
The client has not self-identified as a perpetrator of Family Violence/Aggression or violence against others, but I have reason to believe due to:
Concerns collaterals have reported
Arrests/charges for Family Violence
Behavior that caseworker has witnessed is indicative of Domestic Violence
Outcries family members have made
Law enforcement calls to the home
Disciplinary actions taken by school/teachers/administrators
Other
If Other, please explain
Please provide detailed information here about their current CPS case and the concerns of Family Violence:
Identified victims (Select all that apply):
Please select...
Parent/Guardian
Siblings
Partner
Teacher
Classmate(s)
Animals/Pets
Other Family Members
Friends
Immediate Safety Concerns for Victim(s)
Has the client perpetrated physical violence within an intimate relationship or against a family member in the last 60 days?
Please select...
Yes
No
If no, when was the last physically violent incident?
What restrictions has The Department put in place to ensure safety (Safety Plan/PCSP) and what are the terms of those restrictions?
The Client has used/done which of the following in the current/most recent intimate or family relationship (check all that apply):
Emotional/Verbal abuse
Use of a weapon (includes hands/fists)
Stalking
Damaging property
Law enforcement involvement
Financial Control
Coercion
Isolation from friends/family
Intimidation
Rape/Attempted Rape
Threats of harm to self, children, client
Strangulation
Victim has had to seek medical attention for injuries
Victim reports that he/she feels unsafe or afraid
Threats to flee with or hide the child/children
Other
If Other, please explain:
Protective Order
Does this client's victim currently have a protective order?
Please select...
Yes
No
If Yes, check the type of protective order currently in place.
Please select...
Emergency Protective Order
Temporary Protective Order
Final Protective Order
If there is an Emergency Protective Order, what is the expiration date of the Emergency Protective Order?
If the client's victim does not have a protective order, have you discussed seeking a protective order with the victim?
Please select...
Yes
No
Has the victim applied for a protective order?
Please select...
Yes
No
Has the victim verbalized interest in seeking a protective order?
Please select...
Yes
No
Other Victimization History
Has this client had previous involvement with The Department due to Family Violence?
Please select...
Yes, with this partner
Yes, with a previous partner
No prior involvement
Do you plan to refer this client's victim/family members to victim services?
Please select...
Yes
No
If no, please explain:
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 if applicable (suggestions for CPI cases: signed Safety Plan form, Domestic Violence Safety Plan, Police Calls of Service/Police Reports, etc.; for FBSS cases: FBSS Family Plan, signed Safety Plan form, Domestic Violence Safety Plan, Police Calls of Service/Police Reports, etc.; For CVS cases: Temporary Orders following Adversary Hearing, CVS Family Plan, Police Calls of Service/Police Reports, 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
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.