HPD Referral Form HPD Referral Form Thank you for your referral. Please inform the victim that when a staff member reaches out to them from DVAC, it will appear as an unknown call. If this is a crisis situation or the victim needs immediate assistance, please have them access our 24/7 text line at 605-956-5680 or chat with us at www.domesticviolenceactioncenter.org Is the client interested in DVAC services? Yes Declined URGENT (48hr no contact order issues?) Yes No Was an arrest made? Yes No Date of incident: Referring Officer: Referring Officer's email: Phone: Report number: Victim's information Victim name: Victim DOB: Victim's primary language: Victim's safe phone number: Victim's safe email: Where is victim staying currently? Suspect's information Suspect name: Suspect DOB: Suspect's relationship to victim? Intimate Non-intimate SAFETY CONCERNS/CASE INFORMATION: Upload supporting documents to genias@stoptheviolence.org - please include the Report Number in the subject line. If you are human, leave this field blank. Submit Δ
