DOMESTIC FAMILY AND 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 Domestic Family Violence Local Link and where safety is not acute, can be completed over several
appointments with 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 Local Link.
Please refer to DFSV Action Plan Guide on the PHN DFV Online Toolkit 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	

Ms Anna Andrews	
4/8/1998	
test	

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

Does the patient need an interpreter to communicate?	
No	

If yes, specify language/s	

Children & Pregnancy	

Is the Patient Pregnant and/or have baby under 1 year old?	
Yes	

Children’s Name/s and Age/s	

	
Patient Contact Details	

Patient Address	
2 Kennedy Road
BUNDABERG  QLD  4670	
Safe to receive letters?	
No	

Preferred contact number	
	
Safe time/day to call	
	
Safe to leave a message?	
Yes	

Alternate contact number	
	
Safe time/day to call	
	
Safe to leave a message?	
No	

Preferred email	
	
Safe to receive email?	
Yes	

Alternate email	
	
Safe to receive email?	
No	

Person/s Using DFSV	

Name of Person/s Using DFSV	
test	
Relationship to Patient	

Living in same household as patient?	
No	

GP Name / Practice	
Dr A Practitioner
205 Bourbong Street
BUNDABERG  QLD  4670
Phone:1300 788 802
Fax: 07 4151 1896
Provider No: 2426621B
<END OF ESSENTIAL REFERRAL>	

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 Online Toolkit for further information	

1	
Do you feel unsafe to go home after this visit?	
Yes	

2	
Are the abusive behaviour/s getting worse or happening more often?	
No	

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.	
No	

Yes	

No	

4	
Are they jealous or controlling of you, including following/tracking where you are going or isolating you from others?	
No	

5	
Do you rely on them to care for you, and do they use this position to control or hurt you?	
No	

6	
Have they ever threatened to kill you, pets, or your children?	
No	

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)	
Yes	

8	
Have they ever pressured you to do anything sexually that you did not want to do?	
No	

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?	
No	

10	
Does the person using abuse have access to guns?	
No	

11	
Has the person using abuse ever breached an AVO, even if this was not reported to police?	
No	

12	
Does the person using abuse have any known mental illness or a history of drug or alcohol misuse?	
No	

13	
In the last 12 months, have you separated, changed your living arrangement, or are you thinking about doing this?	
No	

IF YES TO QUESTION 1, 2 OR 3:
It is highly encouraged to call:
DFV Local Link 1800 938 227
NSW Domestic Violence Line 1800 65 64 63 (Out of Hours)	
IF YES TO ANY QUESTIONS:
Safety plan before patient leaves appointment.
It is encouraged to send this plan to the DFV Local Link 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

Learn more at DFV Online Toolkit	

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

GP follow up within two weeks.
Book a double appointment with patient. If this isn’t possible, please consider an appointment with a Practice Nurse or follow up directly with the LCP/DFV Local Link.
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 Local Link for triage and on-referral including:
•	Counselling
•	Legal
•	Housing
•	Care coordination
The DFV Local Link 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 Local Link.

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 Local Link) 

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 Local Link? 	No	
Copy of the plan provided to the DFV Local Link	No	
In the event the DFV Local Link is unable to make contact, does the patient consent to being referred to an alternate service	No	
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 Local Link 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	1/11/2023	Review date	1/11/2023	
	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 Local Link.	

Review Notes