DVOTI Renewal- Appendix

Agency Name
Executive Director / DVOTI Contact Person
Contact Phone Number / Contact Email Address
Physical Address / Mailing Address
Geographic Area Served (i.e. county and/or city)
Populations Served (i.e. adults, adolescents, males, females, Spanish speakers, etc.)
Program Sites & Contact Information (List each address separately, if more than one)
Site 1 / Address
Phone #
# of groups offered
Site 2 / Address
Phone #
# of groups offered
Site 3 / Address
Phone #
# of groups offered
Facilitator Name & Position
*Please list only DVOTI staff / Qualifications
(Licensure/Degree/Experience & Languages spoken) / DVOTI Training Received
(number of hours, trainer name, sponsor & training location)
DVOTI Group Schedule
Group Population
(i.e. Men, Women, Spanish, etc.) / Weekday, Start & End Time / Client to Staff Ratio / Max Group Size / Facilitator Name(s)
Other Services Offered by the agency (i.e. DWI classes, Anger Management, etc.)
How does your agency define “recidivism”? Is it a new arrest, a new conviction, self-reported incidents of violence or something else?
DVOTI Policy Updates* (within previous 12-month period) Check either Yes or No.
Yes, there have been DVOTI policy updates in the last year in the areas of:
No, there have been no DVOTI policy updates in the last year.

*DVOTI Policies must be included regardless of whether there were updates made.

Copy of business license (if required) Check either Yes or No.
Yes, attached is the required copy of agency’s business license.
No, a business license is not required (not applicable). Please explain:

Please be sure to attach the following:

  • Current copy of agency’s general liability insurance.
  • Current copy of professional license where applicable.
  • Current copy of professional liability insurance for the staff with college degrees where licensure is required.

I certify that the information in this application is complete and accurate and agree to comply with the minimum criteria pursuant to rule 8.8.7.10 NMAC – Rp, 8.8.7.10 NMAC, 05/29/2009. I certify that all information on file with the CYFD Domestic Violence Unit, including the list of Board of Directors, program forms, curriculum, and personnel is correct and made current by this renewal process.

I agree to use the ODARA Risk Assessment as part of the DVOTI program assessment. I agree to obtain a license number from CYFD for each DVOTI staff member and have all DVOTI staff complete training before providing services as of January 30,2018.

I agree that victim safety will be top priority in the DVOTI program and that the possible effects of victim involvement in homework assignments or projects will be taken strongly into consideration before becoming a part of the agency’s DVOTI program.

I agree to notify the CYFD Domestic Violence Unit, in writing, of any changes to the information provided, including but not limited to, change in Program Director, program location(s), and name of program.

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Signature Date

1