Office for the Prevention of Domestic Violence

Information for Professionals

Social Services

LDSS-4813 - Desk Reference for Domestic Violence Screening Under the Family Violence Option (pdf)

LDSS-4813

Under the Family Violence Option, all applicants and recipients of Temporary Assistance must be screened for domestic violence using the Domestic Violence Screening Form (LDSS - 4583) at:

APPLICATION - RECERTIFICATION - ANY TIME CLIENT REQUESTS
COMPLETING THE DOMESTIC VIOLENCE SCREENING FORM IS VOLUNTARY AND ANSWERS ARE CONFIDENTIAL.
SCREENING PROCESS:

The following provides a sample guide for workers to use when explaining the Family Violence Option to clients:

GUIDE FOR STAFF RESPONSIBLE FOR DOMESTIC VIOLENCE SCREENING

As part of your interview, I need to discuss domestic violence and a program called the Family Violence Option. We discuss this with everyone who applies or recertifies for temporary assistance. As part of the application/recertification packet, you should have received a copy of the Handout to All Applicants for Welfare. Please read this handout which will give you information about domestic violence. A person may be a victim of domestic violence if their partner or ex-partner does any of the following:

Also, please read the Domestic Violence Screening Form.You are not required to fill out this screening form. Answering the questions on this form is voluntary. It is NOT an eligibility requirement and will NOT affect your temporary assistance grant. Answers are confidential.

The purpose of the Domestic Violence Screening Form is to determine if you want a referral to meet with the Domestic Violence Liaison (DVL). Since you are applying for temporary assistance, you must meet certain requirements which will be explained to you during your eligibility interview.

The meeting with the specially trained DVL will help you figure out whether meeting any of the requirements would make it more difficult for you or your children to escape from domestic violence or subject you to further risk. You may be able to get a temporary delay (waiver) from the requirement(s) because of domestic violence. Some of the requirements are that you:

If you only need to get information on domestic violence services, you may not need to see the DVL. You may contact the domestic violence service provider(s) directly. I can give you the domestic violence information for our county or you may meet with the DVL for more information.

Any information that you share with the DVL is voluntary and confidential. However, information about neglect or abuse of children will be reported to child protective services.

You may decide not to fill out this form right now, but you are free to do so at any time. You could first find out about the requirements and then, if you decide to meet with the DVL, you could fill out the screening form. You can ask to see the DVL at any time.

If you wish to meet with the DVL, check "Yes" on the form and sign your name.

Developed by the NYS Office of Temporary and Disability Assistance in conjunction with the NYS Office of Children & Family Services, the NYS Office for the Prevention of Domestic Violence and the Professional Development Program, Rockefeller College, University at Albany.


NOTES TO WORKER:
COMPLETING THE DOMESTIC VIOLENCE SCREENING FORM AND REFERRALS

There are seven possible ways that a client can respond to the completion of the screening form:

  1. Client checks Yes, signs the form and wants to see the Domestic Violence Liaison (DVL).
  1. Client checks Yes, signs the form and does not want to see the Domestic Violence Liaison.
  1. Client checks Yes, but does not sign the form.
  1. Client checks No on the screening form.
  1. Client declines to complete the form.
  1. Client checks no or is not willing to fill out the form but wants to see the DVL.
  1. Client checks no or is not willing to fill out form but discloses domestic violence during interview.

Please remember to forward all completed screening forms (checked either Yes or No) to the Domestic Violence Liaison. No specific references to domestic violence screening or assessment should be made in the case record.