Nc Council For Women And Domestic Violence Commission Page 2
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4. Explanation of why referrals were not enrolled
(Count each client once using the main reason
for non-enrollment)
Male Clients
Female Clients
Spanish Speaking Clients
___ # Substance Abuse
___ # Substance Abuse
___ # Substance Abuse
___ # Mental Health
___ # Mental Health
___ # Mental Health
___ # Probation Revoked
___ # Probation Revoked
___ # Probation Revoked
___ # New Charges
___ # New Charges
___ # New Charges
___ # No Shows
___ # No Shows
___ # No Shows
___ # No Spanish service to offer
_______________#Other, list
______________#Other, list
_____________#Other, list
B.
PARTICIPANT OUTCOME
(S
/
/
)
TILL ENROLLED
COMPLETED
TERMINATED
1. Total # of participants still enrolled in all groups this quarter:
____ Total # in all gps
____Male ____ Female
M____ F____ Enrolled in Spanish Speaking Groups
2. Total # of participants completing program this quarter:
____ Total # completing all gps
____Male ____ Female
M____ F____ Enrolled in Spanish Speaking Groups
3. Total # of participants terminated from program this quarter:
____ Total terminated all gps
____ Male ____ Female
M____ F____ Enrolled in Spanish Speaking Groups
4. Reason for termination of each client counted in question 3
: (Count one reason per client terminated - totals
should equal the totals above in # B- 3)
M
ale Client
Female Client
Spanish Speaking Groups
Excessive Absences
_____ Excessive Absences
_____ Excessive Absences
_____
_____ Non-compliance w/gp rules
_____ Non-compliance w/gp rules _____ Non-compliance w/gp rules
_____ Recurrence of Violence
_____ Recurrence of Violence
_____ Recurrence of Violence
_____ Substance Abuse
_____ Substance Abuse
_____ Substance Abuse
_____ Arrest/Probation Violation
_____ Arrest/Probation Violation _____ Arrest/Probation Violation
_____ Non-Payment of Fees
_____ Non-Payment of Fees
_____ Non-Payment of Fees
_____ Other
_____ Other
_____ Other
_____ Total # Terminated
_____ Total # Terminated
_____ Total # Terminated
C. V
S
ICTIM
AFETY
(
)
TOTAL NUMBERS SHOULD ROUGHLY CORRESPOND TO REFERRAL NUMBERS
1. Total of ATP program information letters sent to victims: __________
2. Total returned correspondence (e.g.: unable to deliver, returned by sender): _________
3. Number of victims unable to contact (e.g.: no contact information): __________
4. Number of victims requesting no contact: _________
5. Number of victims spoken to via phone or in person: _________
6. Number of victims notified after client completes sessions: ________
7. Number of victims notified when client is terminated: ________
8. Number of contacts made with Victim Service Provider (DV agency) on court ordered cases:______
Due Dates
E-mail, Fax, or mail to: NCCFW/DVC
Statistical Forms are due 2 weeks after the end of
Attn: Kathleen Balogh
the reporting quarter:
46 Haywood St. #309
July 15th
Asheville, NC 28801
th
Oct. 15
Fax: 828-251-6062
Jan. 15th
Kathleen.balogh@doa.nc.gov
or
th
April 15
Deborah.compton@doa.nc.gov
Form may be downloaded from NC Council for Women/Domestic Violence Commission website at:
Revised 6/08
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