Mothering Through Domestic Violence Interest & Referral Form

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For the Advocacy Center's 6 week psycho-educational group for mothers with past experiences of domestic violence.

Our Fall 2022 MTDV group starts on Wednesday September 21 and will meet once a week for 6 weeks ending on October 26. We expect to be offering this group again in the winter of 2023. Please email Taniqua Stewart at tstewart@actompkins.org if you have questions about our MTDV group.

Person interested in Mothering through Domestic Violence *

I am interested in MTDV group myself

I am doing this form on behalf of someone else, and the mother being referred is aware of this referral and has given permission for me to share their information with the Advocacy Center.

Mother's name *

Mother's phone number *

To schedule an intake meeting *

Mother will call Taniqua at 607-277-3203 ext 304

Mother will email Taniqua at tstewart@actompkins.org

Please call mother: it is safe/okay for the Advocacy Center to call the above number but it is NOT okay to leave a message

Please call mother: it is safe/okay for us to call AND to leave a voice message

Is this referral

for yourself

for a mother you are supporting who is interested

part of a CPS service plan

court ordered

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