DCFNE Non-Acute Referral Form

Complete this referral form if you have a patient or client in the District of Columbia who has experienced sexual or domestic violence and would like to speak with a forensic nurse. DCFNE will contact the patient within two business days via their preferred contact method to discuss their medical forensic exam options and other free resources that are available. 

  • Please Note: This form is not monitored 24/7 and is not appropriate for use for emergent or time-sensitive concerns. 
  • For non-emergent but time-sensitive concerns, call the DC Victim Hotline (844-443-5732) and request to speak to the on-call forensic nurse.
  • For medical emergencies, please dial 911 immediately or seek care at the MedStar Washington Hospital Center Emergency Department, where DCFNE services are available around the clock.

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Referring agency *
Referring agency staff member's name *
Referring agency staff member's email address *
Patient's last name *
Patient's first name *
Patient's date of birth *
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Patient's phone number *
Patient's email address *
Is it safe for the forensic nurse to reach out via (check all that apply):   *
Required
Is it safe to call this phone number during week days and regular business hours? (M-F 9am-5pm) *
Is it okay to leave a voicemail on the phone number provided? *
If the forensic nurse is unable to reach you by phone, is it safe for them to email you basic information about their services? *
Please indicate the patient's preferred spoken language. *
Required
Date of most recent assault  *
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Please describe the physical violence, including injuries or areas of concern. *
Additional comments/concerns:
Thank you for submitting a referral!
Please advise your patient/client that DCFNE will contact them within two business days. Walk-in DCFNE services are also available 24/7 at MedStar Washington Hospital's Emergency Department.

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