ADVANCE

ADVANCE – Acknowledging Domestic Violence And Navigating Child protection Effectively 

Audience: Survivors of DV who have a current CPS case due to DV. 

Purpose: To provide education and awareness about sexual & domestic violence, what abusive behaviors, red flags and warning signs look like, tools to move forward in regard to the safety and well-being of group members and their children, and to demonstrate protective behaviors of those involved.

*Indicates required fields.
* The First Name field is required.
* The Last Name field is required.
* The Client DOB is required.
* The Safe Phone Number field is required.
* The Primary Language field is required.
* The Person Being Referred field is required.
*Please note, when providing WCET with a “safe number” that means that you have spoken with this client, verified that it is a safe number, verified that it is safe to leave a voicemail, and verified that it is safe for a WCET employee to identify
* The Workers First Name field is required.
* The Workers Last Name field is required.
* The Workers Email field is required.
* The Workers Phone Number field is required.
* The Workers Supervisor field is required.
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Investigations
Alternative Response
FBSS
Conservatorship

Other Agency Services

*Has the client expressed interest in any of these services? These services are voluntary and cannot be mandatory:
Group Counseling
Individual Counseling
Play/Child/Adolescent Therapy
Advocacy (protective order assistance, legal assistance, CPS case management, Crime Victim’s Compensation, relocation, thrift store, food pantry, court accompaniment
None

*If you are uncertain what services would benefit your client most, please consult Sheri Wayt (903) 295-7846 X 216 sheri@wc-et.org
Caseworkers: Please answer ALL of the following. Note the NO SPACE on this referral form can be left blank if you want your client to receive services from WCET. Please double check the form for accuracy and conflicting information prior to sending, as this delays the time that WCET can help connect your client to services.
*
Yes
No
*
Yes
No
*
Yes
No
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Concerns collaterals have reported
Arrests/charges for Domestic Violence
Behavior worker has witnessed is indicative of DV
Outcries the children have made
Law Enforcement calls to the home
Other
If you have not checked any of the above boxes this client is not appropriate for services, including the ADVANCE Program.
*
Yes
No
*
Yes
No
If you are concerned this client is not safe, please call the WCET crisis line at (800) 441-5555 immediately, and DO NOT rely on this referral as a means to create immediate safety for your client.
*
Yes
No
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Married
Dating
Separated
Divorced
Cohabitating
Ex-dating partner
Separated but considering reconciliation
Abuser is in jail/prison
*
Yes
No
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Separation from abuser
Comforts child/Emotional bond
Believes child’s report of maltreatment
Appeases abuser to deescalate abuse
Understands that her safety and child’s safety are linked
Understands that exposure to abusive behavior is unhealthy for their child
Sends child to another room, a neighbor’s home, etc. when anticipating abuse or when abuse starts
Utilizes services to help with basic needs (i.e. police, courts, shelter services, DV safety planning)
Has demonstrated problem solving skills as demonstrated by past actions
Articulates plan for child safety, i.e. leaving when situation escalates, calling police if protective order is violated
Teaching child to contact 911
Tells child not to intervene
Support from friends and family
Does not place responsibility for violence on child
*
*
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
Threats of harm to self, children, client
Strangulation
Client has had to seek medical attention for injuries
Client reports that he/she feels unsafe or afraid
Threats to flee with or hide the child/children

Protective Order Information

*
Yes
No
* The State field is required.
* The Expiration Date is required.
*
Yes
No
*
Yes
No
*
Yes
No

Other Victimization History

*
This partner
A previous partner
No prior involvement
*
Yes
No
* Current danger indicators are required.