Domestic Violence Intervention Project Risk Assessment Client Referral Form

Domestic Violence Intervention Project

Referral Form for Contact Activity direction for Father to attend DVIP Violence Prevention Programme
Referral Form for DVIP to undertake a Risk Assessment of the Father.

Please ensure ALL details are entered fully to avoid delays in processing your case.

Once completed please email to

Prior to completing the referral form-please can you ensure that the appropriate referral route has been chosen by discussing the case with ?(add name and contact details of DVIP consultant).

Please be advisedthat in order to refer a case for a Contact Activity, (for the father to attend DVIP’s Violence Prevention Programme), the following RESPECT criteria needs to be considered:-

Father accepts responsibility for their behaviour, therefore he cannot be in total denial of his abusive behaviour;
Father shows a willingness to engage with the programme;
Risk of further violence/abuse is low to medium;
Where there is no history of the father using high risk, potentially lethal behaviours (e.g. use of weapons, strangulation, sexual violence, violence during pregnancy);
Both parents’ versions of events are similar;
There is some understanding from the father about the impact on the child(ren) of the domestic violence;
The child(ren) want contact;
There are no complicating factors such as father having mental health issues or substance misuse issues.

Please be advised that in order for DVIP to undertake a Risk Assessment of the Father the domestic violence in the case must be established one or more of the following:-

Finding of Fact hearing where allegations of DV have been proven;
Admissions of physical and/or emotionalabusive behaviour by the Father;
Supporting evidence available such as Convictions, Police Cautions and/or Police call out information, Non Molestation Order/Injunctions being granted by the Court.

Name of referring officer (CAFCASS): / Date of referral:
Address: / Phone:
Email: / How is Risk Assessment to be funded?
Please can you confirm which intervention you require on this case:- (please mark accordingly)
DVIP to undertake a Risk Assessment of Father
Father to attend DVIP Violence Prevention Programme as a Contact Activity Direction
Woman’s Name (respondent): / Man’s Name (applicant):
Race / Ethnicity: / Race / Ethnicity:

Immigration status (British citizen, visa as spouse, applying for citizenship etc):

Date of Birth:

Address: / Address:
Phone (home): / Phone (home):
Phone (work / mobile): / Phone (work / mobile):
Parental responsibility? / Parental responsibility?

Concerns regarding mental health / substance misuse:

Concerns regarding mental health / substance

misuse:

Aggressive behaviour towards professionals?

Special Needs – e.g. Regarding access? / Special Needs – e.g. Regarding access?
Is an interpreter required (specify language)? / Is an interpreter required (specify language)?
Respondent’s Solicitor: / Applicant’s Solicitor:
Name of Firm & Address: / Name of Firm & Address:
Phone / Fax: / Phone / Fax:
Solicitors Ref: / Solicitors Ref:
Children’s names, gender, ages: / Current residency of children and current contact arrangements:
Type of contact applied for:
Other professionals involved (Social Worker / Probation Officer) names and contact details: