CHOICES - Domestic Violence Intervention Program

ABOUT US | REFERRAL FOR DV, DUI & A&D | INFORMATION | CONTACT US

REFERRAL FORM

From:
Email Address:
Office:
Telephone:
Fax:

Offender Name:
Address:
Telephone:
Employer:
Charges:

DOMESTIC VIOLENCE PROGRAM
Men's Domestic Violence Program:	52 weeks only
Women's Domestic Violence Program:	36 weeks 52 weeks
Parenting Group:	yes
Victim's Group for Victim:	yes
Is Offender allowed contact with Victim?	yes no

DUI / ALCOHOL & DRUG PROGRAMS
Alcohol and Drug Assessment Only:	yes
DUI Specific Program:	yes

DHS OR OTHER ASSESSMENTS
DVI:	yes
ODARA:	yes
Cambell Risk Assessment:	yes
Will PO/DHS be paying for any services?	yes no
If PO/DHS will be paying for any services, CHOICES must receive approval in writing prior to clients appointment.

Victim Name:
Relationship:
Victim Telephone:
IS IT SAFE TO CONTACT VICTIM AT THIS NUMBER? yes no
DOES VICTIM WANT CHOICES TO CONTACT HIM/HER? yes no