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Family Violence Intervention

Family Violence Intervention Program Referral Form

If you have any questions about the Family Violence Intervention Program, please contact Angela Johanson at (864)-467-3434, ext. 3313 or johansona@compassofcarolina.org.

If you are a referral source seeking help for an individual who may benefit from the Family Violence Intervention Program, please complete the referral form below. You may send the form electronically or you may download the pdf version and mail it to:

Compass of Carolina
Attn: Angela Johanson
1100 Rutherford Road
Greenville, SC 29609

• Click Here - To Download FVIP Referral Form

  FVIP Referral Form is to be filled out by the referral source only.

Family Violence Intervention Referral Form-Electronic Form

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Referral Source, please enter the following information regarding the referred person

Today's Date

Referred Client Name

Address

Phone

Social Security Number

Case Number

Date Client Must Contact FVIP By

Please check the appropriate boxes

• Perpetrator (Initiator of violence)
• Victim (Recipient of abuse)
• Both partners equally responsible
• Other

Client has also been referred to

• The Phoenix Center
• Mental Health Counseling
• Other

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Please enter the following information regarding the victim. FVIP is required to contact the victim to inform her/him of services and the perpetrator's compliance.

Victim Name

Address

Phone

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Please enter the following information regarding the referring agency

Court/Agency Name

Contact Person

Address

Phone

Fax

Referral Source Email Address *REQUIRED*

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Questions

Comments

Preferred Response

• Email
• Phone
• Fax
• Mail

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For Internal Use

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