Individual Case Report Family Violence Victim Advocate
Individual Case Report Family Violence Victim Advocate Form. This is a Connecticut form and can be use in Family Statewide.
Tags: Individual Case Report Family Violence Victim Advocate, JD-FM-102, Connecticut Statewide, Family
INDIVIDUAL CASE REPORT FAMILY VIOLENCE VICTIM ADVOCATE JD-FM-102 Rev. 7-12 C.G.S. §§ 46b-38c, 52-146k, 54-220 P.A. 12-114, Sec. 3 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instruction: This form contains privileged information and is not to be placed in the Court file. State vs. (Last, first, middle) Court location (Geographic Area) Docket number Name of victim (Last, first, middle) Was victim part of a dual arrest Referral date Yes Victim date of birth No Race/ethnicity White Victim gender Black Limited English proficiency Female Male Yes American Indian Hispanic Other Unknown Disability indicator No Yes No Victim address Telephone number Alternate mailing address Alternate telephone Secondary victim name and address Telephone number Victim requests to have a copy of Protective Order also sent to police in (name of city/town): Victim disclosed that the defendant holds a permit to carry a pistol or revolver? Yes No Not available Unknown Victim disclosed that the defendant possesses one or more firearms? Victim requests to be notified when the Protective Order terminates. Yes No Not available Unknown Victim requests to have a copy of Protective Order sent to the following school or institution of higher education (name, fax number, address): Name and address of Victim Advocate Telephone number Date The Information Below Is Privileged Under Section 52-146k Of The Connecticut General Statutes Relationship to victim Messages may be left with (name of person) Date letter sent Victim Contact Date of initial contact In-person No attempt Accepted services Intake Victim Services Telephone Counseling Telephone Unable to contact/locate Refused services Safety planning General court advocacy Sanctions related Advocacy - outside agency Information and referral - outside agency Referral to D.V. program OVS referral Protective order modification Other Temporary restraining order Victim Agrees To Release The Following Privileged Information To The Court Relationship to defendant Length of relationship Living together at the time of incident Yes No Victim received medical attention at Victim is seeking restitution Defendant has history of mental health issues Police have been involved previously? DCF involved (Defendant) Any physical injuries in this incident? Protective Order Yes No Yes No Yes No Yes No or in writing Children present during incident Yes DV in the last 6 months Defendant has prior history of violence verbally Number of children in household No Defendant has history of substance abuse Describe Describe Describe Describe Full Limited No Contact Residential Stay Away None Continuance dates Victim is requesting the court to: DISTRIBUTION: ORIGINAL - Return to Family Violence Intervention Unit COPY1 - Retained by Victim Advocate American LegalNet, Inc. www.FormsWorkFlow.com