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.