REFFERRING AGENCY:

NAME POSITION:

CONTACT TELEPHONE NUMBER:

DATE OF REFERRAL:

SUMMARY OF CIRCUMSTANCES &REASON FOR REFERRAL:

DOES HELPING THE OFFENDER WITH HIS/HER ISSUES POSE A RISK TO THE VICTIM AND/OR CHILDREN? YES ☐ NO ☐ Please explain :

HAVE POLICE OR PARTNER AGENCIES ASKED THE QUESTION OF THE VICTIM? YES ☐ NO ☐ Please explain :

POLICE USE ONLY

OFFENDER DV HISTORY /OFFENCES