20.A Domestic Violence Individualized Case Management Tool

For CSP Internal Use only.

NOT to be shared outside CSP.

Wyoming Child Support Program

Domestic Violence Individualized Case Management Tool

POSSE NUMBER ________________________________________________________________

NAME OF CUSTOMER ____________________________________________________________

NAME OF CASEWORKER COMPLETING FORM______________________________________


FVI MARKED? Yes _____ No _____


We take the safety of families receiving child support services seriously, and we can modify some of our processes to help with safety concerns. There are a few questions we ask everybody receiving our services to help us provide the right mix of services for your case. We don’t share your answers to these questions with the other parent. We also know that things in relationships can change and so you can change your answers to these questions in the future. OK?

A large percentage of our customers endure some level of domestic abuse. This ranges from put-downs and controlling behavior to very serious violence and threats. Do you feel that your ex has any of these kinds of issues, i.e. is he/she kind of a controlling person? Please tell me about that?




Are you concerned about your or your child(ren)’s physical or emotional safety if you pursue child support? What are you most worried about happening if you pursue child support services? IF NONE, STOP.




Can you tell me what’s happened in the past that’s causing your safety concerns? Try to get some specifics. Helps us gauge how serious violence/intimidation is, level of danger for customer/CS staff. i.e. Worst incident, worst threat, etc.



Does the other parent possibly have access to your email, phone password, GPS tracking?

  • Is it safe to communicate by email? Yes/No Text? Yes/No

  • If it is unsafe to communicate, put a note on Special Circumstances and the Contact popup on the victim’s Person Maintenance screen.

Do either of you have a protection order? Circle one Yes No

Have you had a protection order in the past? Circle one Yes No

  • Which court: ___________________ Expires: _____________ Ask CP to provide to us.

  • Would the customer like information about how to get a protection order? (DV Program)

Have any official agencies been involved now or in past: Circle any that apply: Police/DFS/Hospital

  • Which agencies/where/when? _________________________________________________________


Has the other parent ever been arrested or charged with family violence?

  • Who was victim? ___________________________________________________________________

  • Charged with? _____________________________________________________________________

  • Convicted of? _____________________________________________________________________

  • Which court/where/when? ____________________________________________________________

Do you have any concerns about the other party knowing your address? Does the other party know where you reside currently? Would you like for your address to be protected?

Caseworker has explained the following to applicant:

☐ General overview of child support process

☐ Family Violence Indicator Customer Requests? Yes/No

☐ Good Cause Closure Customer Requests? Yes/No

Only applies if CP receiving POWER and/or Required to cooperate for Medicaid.

☐ Motion for Nondisclosure of customer’s address from Court file Customer Requests? Yes/No

(CSP will file for customer only if there is a current, valid protection order in place. Remind customer that any motions filed with the Court are not guaranteed to be granted)

☐ Phone Appearance for Hearings Customer Requests? Yes/No/NA

☐ No in-person settlement conference Customer Requests? Yes/No/NA

☐ Right to have an Advocate present for hearings Customer Requests? Yes/No

☐ Use Child Support Office as address for victim

☐ Customer establishment of P.O. Box

☐ Use a family member’s address

☐ Provided Domestic Violence Considerations in Child Support Cases (Paper or email)

☐ Saved Notes on POSSE Special Circumstances screen Yes/No/NA

Detailed log notes added to Case Activity Logs Yes/No/NA

_______________ ____________________________________

Date Caseworker


Do you mind if I ask a few additional questions?

Has the other party:

☐ Caused you or your child physical pain not in self defense/or reasonable corporal punishment of child

Describe ________________________________________________________________

☐ Choked or attempted to choke you? Yes/No When?_____________________________

☐ Used/threatened to use a weapon against you or your child

Can you tell me about that? _______________________________________________________

☐ Kept you from using phone to call police

☐ Isolated you from your friends/family

Can you tell me about that? _______________________________________________________

☐ Falsely accused you of cheating

☐ Been violently or constantly jealous or tried to control your daily actions?

Describe: _______________________________________________________________

Has the other party has threatened:

☐ To harm you or the children Which? When? _______________________________________

Substance of threat: ______________________________________________________________

☐ To kill customer or children Which? When? _____________________________________

Substance of threat: _____________________________________________________________

☐ To take children

☐ To get custody of children

☐ To harm household pets

☐ Parties recently separated: Yes/No Date: _________________

If a customer indicates any of these additional questions apply, encourage them to speak with a domestic violence advocate.

Cross Reference


Version Number


Last Revised Date

May 1, 2022