DOMESTIC FAMILY & SEXUAL VIOLENCE (DFSV) ACTION PLAN for MEDICAL DIRECTOR
•	The DFSV Action Plan is used when there has been an indication of DFSV occurring towards the patient to enhance safety and identify risk.
•	The Action Plan doubles as the referral to your DFV Linker and where safety is not acute, can be completed over several appointments:
Partially completed being acceptable to send when referring to link for support early. Please consider sending page 1 at minimum. 
•	Send via fax, Medical Objects or Health Link. Please check HealthPathways for relevant contact details for your regions DFV Linker. 
•	Please refer to DFSV Action Plan Guide on the PHN DFV Web page for further information.
DO NOT PROVIDE PATIENT WITH A COPY OF ANY PART OF THE ACTION PLAN.  IT MAY NOT BE SAFE FOR THEM TO TAKE HOME.
It is recommended that clinicians using this Action Plan seek DFSV training. Please contact your PHN for free training.
Patient Details	

Full Name	
Date of Birth	
Gender/Pronouns	

<<Patient Demographics:First Name>>	
<<Patient Demographics:DOB>>	
<<Patient gender / pronouns >>	

What culture/s does the patient identify with:
ie. Aboriginal, Torres Strait Islander, LGBTIQ+ & Other Nationalities	

<<Cultural identification? ie. ATSI, LGBTIQ, Other?>>	

Does the patient need an interpreter to communicate?	
<<Interpreter?>>	

If yes, specify language/s	
<<Preferred language/s?>>	

Children & Pregnancy	

Is the Patient Pregnant and/or have baby under 1 year old?	
<<Pregnancy or have baby under 1 year old?>>	

Children’s Name/s and Age/s	

<<Children name/s & ages?>>	

Patient Contact Details	

Patient Address	
<<Patient Demographics:Full Address>>	
Safe to receive letters?	
<<Letters safe?>>	

Preferred contact number	
<<Pref contact number?>>	
Safe time/day to call	
<<Pref contact no?>>	
Safe to leave a message?	
<<Pref message safe?>>	

Alternate contact number	
<<Alt contact number?>>	
Safe time/day to call	
<<Alt safe call time?>>	
Safe to leave a message?	
<<Alt message safe?>>	

Preferred email	
<<Pref email address?>>	
Safe to receive email?	
<<Pref email safe?>>	

Alternate email	
<<Alt email address?>>	
Safe to receive email?	
<<Alt email safe?>>	

Person/s Using DFSV	

Name of Person/s Using DFSV	
<<Name user of abuse?>>	
Relationship to Patient	
<<User of abuse relationship to patient?>>	

Living in same household as patient?	
<<User of abuse same household?>>	

GP Name / Practice	
<<Doctor:Full Details>>	

A	
DFSV Risk Assessment
Enter reason for visit: DSWB (Domestic Safety Well-Being)	
<<CONSIDER COMPLETING RISK ASSESSMENT:>CONSIDER COMPLETING RISK ASSESSMENT>
Patient consent is not required for information sharing if the practitioner believes the person is at serious threat and that the information sharing is necessary to lessen the threat (Part 13A of the Crimes (Domestic and Personal Violence) Act 2007)). Please see “Legal” section in the PHN-DFV Resources for further information	

1	
Do you feel unsafe to go home after this visit?	
<<Does the patient feel unsafe to go home?>>	

2	
Are the abusive behaviour/s getting worse or happening more often?	
<<Escalating abusive behaviour?>>	

3	
Has anyone put any pressure to your neck?
IF YES, have you ever felt like you could not breathe, or did you see stars or lose consciousness? (We should be concerned about blood vessels AND airways).
IF YES, did you ever lose bladder or bowel control? (Indicators of strangulation continuing beyond unconsciousness)
Do you have any pain or symptoms (refer to SOS card for list of seen and unseen impacts)?
If current symptoms and signs, please send to ED with referral letter or consider a scan.	
<<Any attempts to strangle, choke, or asphyxiate?>>	

<<IF YES, have you ever felt like you could not breath>>	

<<IF YES, did you ever lose bladder or bowel control?>>	

4	
Are they jealous or controlling of you, including following/tracking where you are going or isolating you from others?	
<<Any coercive, stalking, controlling behaviour?>>	

5	
Do you rely on them to care for you, and do they use this position to control or hurt you?	
<<Disability or Elder abuse?>>	

6	
Have they ever threatened to kill you, pets, or your children?	
<<Threatened to kill patient or Children?>>	

7	
Have they ever threatened or hurt you or your children inclusive of weapons or other objects?
Please specify in additional information (with weapon, punching, slapping, grabbing, pushing, etc)	
<<Physical Threats or harm inclusive of weapons?>>	

8	
Have they ever pressured you to do anything sexually that you did not want to do?	
<<Any sexual assault?>>	

9	
Have they ever threatened or physically hurt you while you were pregnant or made you do something that you didn’t want to do while you were pregnant to hurt the baby?	
<<Threats or harm to unborn child?>>	

10	
Does the person using abuse have access to guns?	
<<Access to firearms?>>	

11	
Has the person using abuse ever breached an AVO, even if this was not reported to police?	
<<Any AVO or breaches of AVO?>>	

12	
Does the person using abuse have any known mental illness or a history of drug or alcohol misuse?	
<<Abuser mental illness, D&A misuse?>>	

13	
In the last 12 months, have you separated, changed your living arrangement, or are you thinking about doing this?	
<<Has the patient recently left or is planning to leave?>>	

IF YES TO QUESTION 1, 2 OR 3:
It is highly encouraged to call:
DFV Linker on 47 284803 (during Business Hours) OR NSW Domestic Violence Line 1800 65 64 63 (Out of Hours)
Call 000 if immediate assistance is required	
IF YES TO ANY QUESTIONS:
Safety plan before patient leaves appointment.
It is encouraged to send this plan to the DFV Linker via secure messaging	
IF NO TO ALL QUESTIONS:
Safety planning may be left to the follow up appointment.	

Additional Relevant Information
(If specific Risk indicators or patterns of abuse are increasing in severity. Consider existing patient supports and criminal affiliations)	
<Additional Relevant Information>

	

	B	
Safety Planning
Plan with your patient how they and their children can remain safe	

When Safety Planning consider:
Supportive people and/or organisations, Safe neighbours
Escape bag – medication, clothing, important docs, comforter toy for children
Safety of children, Safety of pets
Safe communication
Electronic communications and social media
When to call the police
Consider the patient downloading the Daisy App

Safety Planning Toolkits:
RANSW Safe from Violence Booklet
1800RESPECT Safety Planning Checklist
Esafety Checklist
1800RESPECT Escape Bag Checklist

Go to the DFSV Action Plan Guide for more information 

C	
Review & follow up
Enter reason for visit: DSWB
(Domestic Safety Well-Being)	

GP follow up within two weeks.
Book a dSoble appointment with patient. If this isn’t possible, please consider an appointment with a Practice Nurse or follow up directly with the DFV Linker.
For patient safety, please consider bulk billing.	

Patient Plan	
Patient needs	Goals	Management	Referrals	
Identify needs as identified by the patient.	Record the goals agreed to by the patient and GP and any actions the patient will need to take	Treatments, actions, and support services to achieve patient goals	DFSV is complex and multilayered and requires an interdisciplinary response.	
☐ Information and advice only

☐ Would like to stay in the relationship but wants the abuse and violence to stop.

☐ Wants to leave the relationship

☐ Requires an immediate response and crisis accommodation.

Other issues -	☐ Ensure safety of patient and children

☐ Address DFV impacts on children’s developmental milestones, particularly speech, language, and communication and behavioural issues.

☐ Consider social and emotional difficulties for both adult and child. 

☐ Patient is safe in their home (person using violence/abuse leaves). Patient is engaged/seeking support)	Attend to any injuries 
Refer to DFV Linker for triage and on-referral including:
•	Counselling
•	Legal
•	Housing
•	Care coordination
The DFV Linker will provide feedback as to the outcome of the referral via secure messaging
Where a child may be at risk of harm, call the NSW Health Child Well-being Unit on 1300 480 420 to determine if a report is required.

Complete a strengths-based report which includes the protective behaviours of the parent and any referrals made i.e., engaging in safety planning and allied health services for children’s needs.
	All referrals should be directed to your DFV Linker.

When making referral to DFV service, at minimum provide information about contact safety, cultural or other needs on Page 1. Please provide all pages 1, 2 & 3 when appropriate to do so.

Consider referral to paediatric specialist services such as speech pathologists, occupational therapy, behavioural and attachment therapists with knowledge and expertise in DFSV.
If patient only wants counselling, consider application to Victims Service’s for counselling (if not already completed by the DFV Linker) 

Relationship or marriage counselling is not appropriate for DFSV.
Patients involved in DFSV need to be seen by separate clinicians and support services.	
Safety & Resilience	☐ Existing Supports (Family, friends, neighbours, professional services)	☐ Patient confident safety plan will keep them safe

	☐ Set small and simple goals for self-care
☐ Celebrate each step taken towards safety and empowerment	
Has the patient consented to referral to the DFV Linker? 	<<Consent for referral to the DFV Linker?>>	
Copy of the plan provided to the DFV Linker	<<Copy of plan provided to DFV Linker?>>	
In the event the DFV Linker is unable to make contact, does the patient consent to being referred to an alternate service	<<Consent refer alt service if DFVLinker uncontactabl>>	
Completing the plan
On completion of the plan, the GP is to record that s/he has discussed with the patient:
•	risk assessment and safety planning,
•	all aspects of the plan and the agreed date for review (Practice Nurse can complete review),
•	referral to the DFV Linker for specialist support and care coordination.	Signed consent required
__________________________________________________
Scan back into the patient file and send via secure messaging.
According to Part 13A of the Crimes (Domestic and Personal Violence) Act 2007, patient consent is not required for information sharing if the practitioner believes the person is at serious threat and that information sharing is necessary to lessen the threat.	
Date plan completed	<<Date plan completed?>>	Review date	<<Review date?>>	
	Enter Reason for visit: DSWB	
GP follow up within two weeks. If this isn’t possible, please consider an appointment with a Practice Nurse or the DFV Linker.	

Review Notes