VAWA Referral Form

Attorney Name: Attorney Name: First Last
Attorney Phone: Attorney Phone: - ### - ### ####
Attorney Email:

Confirm Email Address
Legal Assistant/ Paralegal Name: Legal Assistant/ Paralegal Name: First Last
Legal Assistant/ Paralegal Email Address:

Confirm Email Address:
Date report is needed by: Date report is needed by: / MM / DD YYYY

Please note that evaluations completed within one year of the expected court date are considered current. Evaluations completed outside of that may require an updated evaluation.
Is this date flexible?

Is this date flexible? Yes No Other Other
Are you affiliated with any of these organizations?

Are you affiliated with any of these organizations? SOAR IRCO LCS Catholic Charities ICS None Other Other
How much can your organization contribute to the cost of this evaluation?
Is this an Equity Corps referral?

Is this an Equity Corps referral? Yes No
If this is an ECO case, what is the client ECO ID number?
Do you prefer that the evaluation be done via telehealth or in person?

Do you prefer that the evaluation be done via telehealth or in person? Telehealth In person No preference Other Other
Is the client comfortable completing intake forms electronically?

Is the client comfortable completing intake forms electronically? Yes No
Is the client comfortable setting up a video appointment electronically?

Is the client comfortable setting up a video appointment electronically? Yes No
Will the client require assistance with the above?

Will the client require assistance with the above? Yes No
If needed, can you provide an office space for the evaluation?

If needed, can you provide an office space for the evaluation? Yes No
Does your client consent to the use of an interpreter?

Does your client consent to the use of an interpreter? Yes No
Client Information
Name: Name: First Last
Is it safe to contact the client directly?

Is it safe to contact the client directly? Yes No
Please list the best form of communication with the client:
Phone: Phone: - ### - ### ####
Email:

Confirm Email Address:
Date of Birth: Date of Birth: / MM / DD YYYY
Age:
Birthplace:
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Occupation:
Employer:
Education:
Language of choice:
Children and ages:
List any known major health issues:
Current Relationship Status

Current Relationship Status Married Single In a relationship Other Other
Number of years in current relationship:
What relationship is this VAWA application based on?
Relevant history:

Please note any known traumas, medical or other relevant history.
Define the questions you want answered in the psychological evaluation:
This client may qualify for funding. Please state the estimated monthly income & number of people living in the household:
Will testimony in court be needed?

Will testimony in court be needed? Yes No Other Other
Spam Protection. Please answer this simple question:
4, 5, 6, 7 : the 2nd number is?

VAWA Referral Form

VAWA Referral Form

Client Information