Family Advocate Program Referral Form
Date of Referral
*
/
Month
/
Day
Year
Date
Referred By:
*
First and Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Role In Case
*
Ex: Family Advocate and CAC, DFPS, Detective and Jurisdiction
Services Requested (Click All that Apply)
*
Family Advocate (Case Management/Social Services)
Clinical Services (Counseling)
Child
Please list primary victim in case.
Child's Name:
*
First and Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Gender:
*
Male
Female
Hispanic/Latino Origin?
*
Yes
No
Ethnicity:
*
American Indian/Alaska Native
Asian
Black/African American
White
Multi-Racial
Unknown
Native Hawaiian/Other Pacific Islander
Other
Language
*
Relationship to AP:
*
VOCA Special Classification:
Homeless (Shelter, Hotel, RTC)
Immigrants/Refugees/Asylum Seekers
LGBTQ
Victim w/ Limited English Proficiency
Legal Guardian Information
Legal Guardian's Name
*
First and Last Name
Relationship to Victim
*
Date of Birth
*
/
Month
/
Day
Year
Date
Gender:
*
Male
Female
Hispanic/Latino Origin?
*
Yes
No
Ethnicity:
*
American Indian/Alaska Native
Asian
Black/African American
White
Multi-Racial
Unknown
Native Hawaiian/Other Pacific Islander
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone
*
-
Area Code
Phone Number
Secondary Phone
-
Area Code
Phone Number
Email
Language
*
VOCA Special Classification:
Homeless (Shelter, Hotel, RTC)
Immigrants/Refugees/Asylum Seekers
LGBTQ
Victim w/ Limited English Proficiency
Military: Active
Miltary: Veteran
Caregiver (If Different from Legal Guardian)
Name
First and Last Name
Relationship to Victim
Date of Birth
/
Month
/
Day
Year
Date
Gender:
Male
Female
Hispanic/Latino Origin?
Yes
No
Ethnicity:
American Indian/Alaska Native
Asian
Black/African American
White
Multi-Racial
Unknown
Native Hawaiian/Other Pacific Islander
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone
-
Area Code
Phone Number
Email
Language
VOCA Special Classification:
Homeless (Shelter, Hotel, RTC)
Immigrants/Refugees/Asylum Seekers
LGBTQ
Victim w/ Limited English Proficiency
Alleged Perpetrator/Suspect Information
Alleged AP/Suspect's Name
*
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
AP's Estimated Age (if DOB unknown):
Gender:
*
Male
Female
Ethnicity:
*
American Indian/Alaska Native
Asian
Black/African American
White
Multi-Racial
Unknown
Native Hawaiian/Other Pacific Islander
Other
Hispanic/Latino Origin?
*
Yes
No
Relationship to Victim
*
Investigation Information
Type of Abuse (click all that apply):
*
Sexual Abuse
Witness to Sexual Abuse
Physical Abuse
Witness to Physical Abuse
Child Fatality
Neglectful Supervision
Sex Trafficking
Child with Problematic Sexual Behaviors
Witness to Domestic Violence
Survivors of Homicide
Medical Child Abuse
Other
Type of SXAB (click all that apply):
Fondling Over Clothes
Fondling Under Clothes
Digital Penetration- Vagina
Digital Penetration- Anus
Penile-Vaginal Penetration
Penile-Anal Penetration
Oral to VIC
Oral to SUS
Exposure by SUS
Voyeurism by SUS
Exposure to Pornography
Use of Object in Abuse
Pregnancy of VIC
Hx of Abortion by VIC
Force sex act with other
One time Occurrence
Multiple Occurrences
Sexually Acting Out Behaviors
Other
Type of PHAB (click all that apply):
Failure to Thrive
Hospitalization
Abusive Head Trauma
Blunt Force Trauma
Fracture to arm(s)
Fracture to leg(s)
Fracture to ribs
Fracture to head
Other
Type of Neglect/NGSUP (click all that apply):
Drug use in home
Mental illness impacting ability to supervise/care
Other
Forensic Interview Complete
*
Yes
No
Not Applicable
Unknown
Forensic Interview Completed by:
Alliance For Children
Other Texas CAC
Other
Confirmed Outcry
*
Yes
No
Inconclusive
Unknown
Medical Exam Completed
*
Yes
No
Not Applicable
Unknown
AP/SUS Arrested?
*
Yes
No
Not Applicable
Unknown
Case Summary:
*
DFPS Worker (If none, please list Closed at Intake, LE Only)
*
First and Last Name
DFPS Email
example@example.com
DFPS Phone Number
-
Area Code
Phone Number
DFPS # (If none, list N/A)
*
Law Enforcement Investigator (If none, list No Offense, DFPS Only)
*
First and Last Name
LE Email
example@example.com
LE Phone Number
-
Area Code
Phone Number
LE Jurisdiction
LE Offense # (If none, list N/A)
*
Supplemental Information such as DFPS report/LE Reports *This is for informational purposes only. Alliance For Children does not maintain a copy of your agency’s records.
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