Advocate Name *

First Name

Last Name

Services Provided This Month *

Please select all services provided to individuals in your case this month. Each service type includes examples, but is NOT all inclusive.

Individual advocacy – This should be selected for every case. (Examples: School meetings, court hearings, CFTMs, FCRB)

Information about the criminal justice process – (Examples: Explaining CASA, requesting and explaining Urine Drug Screen process)

Referral to other services, supports, and resources – (Examples: Recommendations to therapeutic agencies, substance abuse centers, etc. in court reports and in person/by phone, specific provider contact information for permanency plan goals.)

Referral to other victim service programs – (Examples: Recommendations made in court reports and in person/by phone, referrals to Family Justice Center, referrals to support groups)

Other emergency justice related assistance – (Examples: Referral to Child Protective Services, Mobile Crisis Communication)

Information about victim rights, how to obtain notifications, etc. – (Examples: Sharing Victim Notification System website, OVC Directory of Crime Victim Services)

Assists potential recipients in seeking crime victim compensation benefits

Not Applicable – I did not have an active case this reporting month.

Supervisor Needed Regarding Case

Let us know if you need a supervisor to contact you regarding your Monthly Check-In Case information and planning for this upcoming month's needs for your child/case.

Yes

No

Date *

MM

DD

YYYY