Race/ethnicity
Was victim part of a dual arrest
Victim is requesting the court to:
Victim disclosed that the defendant possesses or has access to ammunition?
INDIVIDUAL CASE REPORT FAMILY
VIOLENCE VICTIM ADVOCATE
JD-FM-102 Rev. 5-19
C.G.S. §§ 46b-38c, 52-146k, 54-220
The information below is privileged under section 52-146k of the Connecticut General Statutes
Distribution: Original - Return to Family Violence Intervention Unit Copy - Retained by Victim Advocate
Victim agrees to release the following privileged information to the court
Protective Order
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
Instruction:
This form contains privileged information and is not to be placed in the court file.
State v. (Last, first, middle) Court location (Geographic Area)
Docket number
Name of victim (Last, first, middle)
Referral date
Yes No
Victim date of birth
White Black Hispanic Other Unknown
American Indian
Victim address Telephone number
Alternate mailing address
Secondary victim name and address
Alternate telephone
Telephone number
Victim disclosed that the defendant holds a permit to carry a pistol or revolver?
Yes No Not available Unknown
Victim disclosed that the defendant possesses one or more firearms?
Yes No Not available Unknown
Name and address of Victim Advocate Telephone number Date
Messages may be left with (name of person)
Relationship to victim Telephone
Victim
Contact
Left msg
Telephone
Unable to contact
No attempt
Accepted services
Refused services
Victim
Services
Intake
SRI
Counseling
Safety planning
Info/referral
Court advocacy
Advocacy - outside agency
Referral - DV program
Register CT SAVIN
Victim compensation
PO modification
Sanctions
TRO
OVS referral
Other
Victim received medical attention atVictim is seeking restitution
Length of relationship
Living together at the time of incident
Number of children in household
Children present during incident
Defendant has prior
history of violence
Police have been
involved previously?
DCF involved
(Defendant)
Any physical injuries
in this incident?
Yes No Yes No
Yes
Yes
Yes
Yes
No
No
No
No
Describe
Describe
Describe
Describe
100 Yards Stay Away Limited No ContactResidential Stay Away
None
Continuance dates
Victim gender
Female Male
If limited English proficiency, write primary language spoken
Disability indicator
Yes No
Victim requests to have a copy of Protective
Order also sent to police in (name of city/town):
Victim requests to be notified when the Protective
Order terminates.
in writingverbally or
Relationship to defendant
Victim requests to have a copy of Protective Order sent to the following
school or institution of higher education (name, fax number, address):
Criminal charges Bond Amount
Defendant date of birth
UnknownNot availableNoYes
Defendant
has history of
E-mail
In-person
mental health
substance abuse
Describe
Date of initial contact
Date letter sent
Date e-mail sent
Safe e-mail address
Safe at Home/ACP
