Memorandum Of Agreement printable pdf download

Memorandum of Agreement

The [Domestic Violence Program]

and the [Family Planning Program]

This agreement is by and between [domestic violence program] and [family planning program] to enhance the

response to individuals and families experiencing intimate partner violence in the [locality/region] area.

The parties listed above and whose designated agents have signed this document agree that:

1) The [domestic violence program] and [the family planning program] agree to work collaboratively on the

Project Connect pilot program activities to enhance our response to those experiencing intimate partner

violence.

2) The [domestic violence program] will provide training and ongoing technical assistance on identifying and

responding to intimate partner violence for all staff of [the family planning program].

3) The [family planning program] agrees to use the model intervention identified by Project Connect for

screening for intimate partner violence and participate in evaluation activities, including pre/post survey

for training participants, provider behavior survey, and client outcome survey.

4) When intimate partner violence is identified by [the family planning program], staff will review advocacy

services available in the community and provide referral to the [domestic violence program] or other

appropriate domestic violence services.

5) The [domestic violence program] agrees to provide each individual seeking services as a result of a

referral from the [family planning program] with appropriate safety planning and support services to

address intimate partner violence.

6) The [domestic violence program] agrees to provide materials to the [family planning program] in support

of ongoing training and consultation efforts, as well as awareness materials to distribute to the [family

planning program’s] clients.

7) The [domestic violence program] agrees to develop and maintain up-to-date referral and resource

materials and to make those materials available to the [family planning program].

8) The [domestic violence program] and the [family planning program] will actively partner in a Health

Advisory Council (resource team) created in support of services provided by Project Connect.

9) Representatives of the [domestic violence program] and the [family planning program] will meet at least

once annually to ensure an understanding of the scope of services provided by their respective programs,

review referral policies between agencies, and revisit the terms of this agreement.

We, the undersigned, approve and agree to the terms and conditions as outlined in the Memorandum of

Understanding.

_____________________________

_______________________________

Name

Executive Director

Title

Domestic Violence Program

Family Planning Program

_____________________________

_______________________________

Date

Developed by the Haven Shelter & Services Inc. in Warsaw, Virginia and adapted by the Shelter for Help in Emergency in

Charlottesville, Virginia.

Memorandum Of Agreement