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Domestic Violence Referral of High-Risk Situations

  1. Person submitting the referral
  2. Victim
  3. Safe to call (#1)?
    Is Phone # 1 safe to call?
  4. Safe to call (#2)?
    Is Phone # 2 safe to call?
  5. Safe to email?
  6. Reason(s) for referral / concerns
  7. Offender
  8. Additional Information / References
  9. Police report numbers (please include agency)
  10. Cause numbers (and prosecutor if known)
  11. DCS, Prevail, LAP, Mental Health, Youth Assistance, etc.
  12. Leave This Blank:

  13. This field is not part of the form submission.