Form JD-FM-102 "Individual Case Report Family Violence Victim Advocate" - Connecticut

What Is Form JD-FM-102?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-FM-102 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-FM-102 "Individual Case Report Family Violence Victim Advocate" - Connecticut

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INDIVIDUAL CASE REPORT FAMILY
STATE OF CONNECTICUT
VIOLENCE VICTIM ADVOCATE
SUPERIOR COURT
JD-FM-102 Rev. 3-18
www.jud.ct.gov
Instruction:
C.G.S. §§ 46b-38c, 52-146k, 54-220
This form contains privileged information and is not to be placed in the Court file.
State vs. (Last, first, middle)
Defendant date of birth
Court location (Geographic Area)
Docket number
Criminal charges
Bond Amount
Referral date
Name of victim (Last, first, middle)
Was victim part of a dual arrest
Yes
No
Victim date of birth
Race/ethnicity
American
White
Black
Hispanic
Other
Unknown
Indian
If limited English proficiency, write primary language spoken
Victim gender
Disability indicator
Female
Male
Yes
No
Victim address
Telephone number
Alternate mailing address/e-mail address
Alternate telephone
Secondary victim name and address
Telephone number
Victim requests to have a copy of Protective
Victim disclosed that the defendant holds a permit to carry a pistol or revolver?
Yes
No
Not available
Unknown
Order also sent to police in (name of city/town):
Victim disclosed that the defendant possesses one or more firearms?
Yes
No
Not available
Unknown
Victim requests to be notified when the
Victim disclosed that the defendant possesses or has access to ammunition?
Protective Order terminates.
Yes
No
Not available
Unknown
Victim requests to have a copy of Protective Order sent to the following
school or institution of higher education (name, fax number, address):
Name and address of Victim Advocate
Telephone number
Date
The information below is privileged under section 52-146k of the Connecticut General Statutes
Messages may be left with (name of person)
Relationship to victim
Telephone
Date letter sent
Date of initial contact
Victim
In-person
Telephone
Unable to contact/locate
Contact
No attempt
Accepted services
Refused services
Intake
Counseling
Safety planning
General court advocacy
Sanctions related
Victim
Advocacy - outside agency
Information and referral - outside agency
Referral to D.V. program
Services
Protective order
Temporary
OVS referral
SRI
Other
modification
restraining order
Victim agrees to release the following privileged information to the court
verbally
or
in writing
Relationship to defendant
Length of relationship
Living together at the time of incident
Number of children in household
Children present during incident
Yes
No
Yes
No
DV in the last 6 months
Victim received medical attention at
Victim is seeking restitution
Defendant has history of mental health issues
Defendant has history of substance abuse
Yes
Describe
Defendant has prior
history of violence
No
Yes
Describe
Police have been
involved previously?
No
Yes
Describe
DCF involved
(Defendant)
No
Yes
Describe
Any physical injuries
in this incident?
No
Continuance dates
Protective Order
Limited
No Contact
Residential Stay Away
100 Yards Stay Away
None
Victim is requesting the court to:
DISTRIBUTION: ORIGINAL - Return to Family Violence Intervention Unit
COPY1 - Retained by Victim Advocate
Print Form
Reset Form
INDIVIDUAL CASE REPORT FAMILY
STATE OF CONNECTICUT
VIOLENCE VICTIM ADVOCATE
SUPERIOR COURT
JD-FM-102 Rev. 3-18
www.jud.ct.gov
Instruction:
C.G.S. §§ 46b-38c, 52-146k, 54-220
This form contains privileged information and is not to be placed in the Court file.
State vs. (Last, first, middle)
Defendant date of birth
Court location (Geographic Area)
Docket number
Criminal charges
Bond Amount
Referral date
Name of victim (Last, first, middle)
Was victim part of a dual arrest
Yes
No
Victim date of birth
Race/ethnicity
American
White
Black
Hispanic
Other
Unknown
Indian
If limited English proficiency, write primary language spoken
Victim gender
Disability indicator
Female
Male
Yes
No
Victim address
Telephone number
Alternate mailing address/e-mail address
Alternate telephone
Secondary victim name and address
Telephone number
Victim requests to have a copy of Protective
Victim disclosed that the defendant holds a permit to carry a pistol or revolver?
Yes
No
Not available
Unknown
Order also sent to police in (name of city/town):
Victim disclosed that the defendant possesses one or more firearms?
Yes
No
Not available
Unknown
Victim requests to be notified when the
Victim disclosed that the defendant possesses or has access to ammunition?
Protective Order terminates.
Yes
No
Not available
Unknown
Victim requests to have a copy of Protective Order sent to the following
school or institution of higher education (name, fax number, address):
Name and address of Victim Advocate
Telephone number
Date
The information below is privileged under section 52-146k of the Connecticut General Statutes
Messages may be left with (name of person)
Relationship to victim
Telephone
Date letter sent
Date of initial contact
Victim
In-person
Telephone
Unable to contact/locate
Contact
No attempt
Accepted services
Refused services
Intake
Counseling
Safety planning
General court advocacy
Sanctions related
Victim
Advocacy - outside agency
Information and referral - outside agency
Referral to D.V. program
Services
Protective order
Temporary
OVS referral
SRI
Other
modification
restraining order
Victim agrees to release the following privileged information to the court
verbally
or
in writing
Relationship to defendant
Length of relationship
Living together at the time of incident
Number of children in household
Children present during incident
Yes
No
Yes
No
DV in the last 6 months
Victim received medical attention at
Victim is seeking restitution
Defendant has history of mental health issues
Defendant has history of substance abuse
Yes
Describe
Defendant has prior
history of violence
No
Yes
Describe
Police have been
involved previously?
No
Yes
Describe
DCF involved
(Defendant)
No
Yes
Describe
Any physical injuries
in this incident?
No
Continuance dates
Protective Order
Limited
No Contact
Residential Stay Away
100 Yards Stay Away
None
Victim is requesting the court to:
DISTRIBUTION: ORIGINAL - Return to Family Violence Intervention Unit
COPY1 - Retained by Victim Advocate
Print Form
Reset Form