M3

MIECHV ENROLLMENT TOOL

Index Parent

To be completed within 6 months of parent’s enrollment

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID #:

Name of Index Parent:

Part A: IPV Screening

IPV refers to physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner. To meet the measure, all clients must be screened for IPV within 6 months of enrollment, regardless of relationship status or if IPV has been previously identified.

1.	Relationship Assessment Tool completed?

Yes, completed → Date tool completed: / / 20 → Go to Question 1a.

1a. If Yes, result of Relationship Assessment Tool:

Score of 20 or higher → Go to Part B: IPV Referral.

Score of 19 or lower

No, not completed → Complete IPV Screening at future visit before the client reaches

6-months post-enrollment, then complete another M3 form and update in THEO.

Part B: IPV Referral

To meet the measure, IPV Referral information must be given at least once if the client scores 20 or higher on the Relationship Assessment Tool during a MIECHV screening.

2. If a Score of 20 or higher, did you give referral information? *See examples below

Yes

No → Clients who screen positive should be provided information at least once on available referral services. The focus is on provision of information, not whether the client received IPV referral services, as a client may not be ready or able to safely access a referral service. Provide Referral Information at future visit and update M3 form in THEO: Q2. Change Selection to “Yes”.

*Referral information can include:	Domestic violence advocacy program, shelter or hotlines	“Healthy Moms, Happy Babies” cards	Housing options or emergency shelter services	Legal advocacy and assistance	Crisis assistance	Support groups	Counseling services to address related needs such as depression or substance use