SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA Family Court Services 201 North First Street San José, California 95113 (408) 534-5760 NOTICE Please complete & return this form to Family Court Services before your next appointment. NON-CONFIDENTIAL DOMESTIC VIOLENCE/ ABUSE QUESTIONNAIRE (Physical, Emotional, Verbal and Economic Abuse) Name: (Please Print) Case Number: FCS Number: Other Parent's Name: The following information will be used by Family Court Services in assessing any history of domestic violence and/or emotional abuse in the family so that: 1) mediations and investigations may be conducted in the most appropriate manner; 2) any recommendations are based on an accurate understanding of the domestic violence issues, and 3) any agreements or recommendations include appropriate safety considerations. The information you provide on this form is NOT confidential. Family Court Services may disclose any of the information to third parties, including law enforcement or child welfare agencies under appropriate circumstances, and the information could be used against you in a criminal prosecution. You may want to consult with your attorney before submitting this form. The other parent, at his or her request and with a signed Protective Order, will be provided a copy of your responses and will have the opportunity to respond. Any information you do provide must be true and accurate and not intended to mislead. You DO NOT have to answer questions if you believe that by doing so, you may endanger yourself or your children. This form is not required. If you elect not to answer some or any of the questions, your failure to answer will NOT be used against you by Family Court Services. Check here if, for any reason, you need help in completing this form. Check here if you DO NOT wish to complete this form. Date of Parties' Separation: Length of Relationship or Marriage: Has there been a Family Code §3044 Finding? FM-1076 REV 11/25/08 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com SAFETY ASSESSMENT/LEVEL OF VIOLENCE/LEVEL (Source: Adapted by Family Court Services, 2007 from Danger Assessment Scale 2001 by Jackie Campbell.) Yes 1. 2. 3. 4. 5. 6. 7. 8. 9. Has the other parent been violent toward a previous partner? (If you were his/her 1st relationship, check N/A.) Has the physical violence increased in severity or frequency over the past year before you decided to leave him her/her? Has he/she ever used a weapon against you or threatened you with a weapon? Did he/she ever try to choke you (strangle/cut off air with hands or object around neck)? Does he/she own/have access to a gun? Has he/she ever forced you to have sex when you did not wish to do so? Doe he/she use drugs? By drugs, we mean "uppers" or amphetamines, speed, angel dust, cocaine, "crack," street drugs or mixture? Has he/she threatened to kill you or the children and/or do you believe he/she is capable of killing you or the children? Does he/she get intoxicated/drunk every day or almost every day? (frequency of drinking) Or does he/she get intoxicated every time he/she drinks (quantity of drinking)? Did he/she control most of all of your daily activities? For instance: isolate you, tell you with whom you can be friends, who you can see, how much money you could use, if you could work, when you could take the car, etc. Have you ever been beaten by him/her while you were pregnant. (If never been pregnant, check N/A) Is he/she violently and constantly jealous of you? (For instance, does he/she say, "If I can't have you, no one can.") Have YOU ever threatened or tried to commit suicide? Has the OTHER PARENT ever threatened or tried to commit suicide? Does he/she threaten to harm your children? Do you have a child that is not the child of your partner? Is the other parent unemployed? Have you left him/her during the past year? (If you have never lived with him/her, check N/A) Are you in the process of divorcing him/her? (If you were never married to him/her check N/A) Do you currently have another intimate partner? Does the other parent follow or spy on you, leave threatening notes, destroy your property, or call you when you don't want him/her to do so? Has the other parent ever violated a protective order or been arrested for charges related to domestic violence, assault, alcohol, illicit drugs? If yes, briefly explain. No N/A 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Do you currently fear for your safety or your child's safety or have any concerns for future safety? If yes, please explain. Other Comments: FM-1076 REV 11/25/08 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PHYSICAL, EMOTIONAL, VERBAL AND ECONOMIC ABUSE Please put a check mark in the correct box. If the OTHER PARENT did or ever threatened to do the violence, mark the column on the LEFT side of the page. If YOU did or ever threatened or were violent, mark the column on the RIGHT side of the page. Please explain where necessary. I. Level of Physical Violence: You Threatened Threatened Threatened 1- 3 Times 1 - 3 Times 4 or More Times Other Parent 1 - 3 Times 4 or More Times Did Pushing, carrying, shoving, grabbing, or restraining you Attempted or actual slapping with an open hand Attempted or actual hitting with a closed hand or fist Pulling your hair Biting or kicking you Hitting you in the head, face, breasts or genital area Attempted or actual choking, strangulation or smothering Tried to hit you with, or throw you out of, a car or truck Burned you Drove recklessly to scare you Threw objects at you Raped you or forced you to have sex Abuse to pets Destruction of property Cruel or sadistic infliction of pain Kidnapped you and/or your child Breaking into and entering your residence Child abuse (describe) Other (describe) II. Level of Emotional, Verbal & Economic Abuse: Other Parent Threatened 1- 3 Times 4 or More Times Did You 4 or More Times Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Did Humiliating, embarrassing, "putting you down" or doing so to the other parent Blaming all problems on you or you blaming the other parent Interrupting other parent's eating or sleeping Not permitting you or you not permitting the other parent to go anywhere by himself/ herself Punishing for contacts with others Demands constant knowledge of whereabouts Making automobile not work, withholding car keys Making telephone not work Threatening family and friends Were your children exposed to violence or to threats? Falsely acc