Domestic Violence Intake Questionnaire Date____________________ Your Name ___________________________________________________________________ [ ] Female [ ] Male Birth Date ___________________ Are you under 18 years of age? [ ] yes [ ] no If yes, name of parent/guardian ________________________ Relationship to you ___________________________ Petitioner’s Place of Birth ______________ Race [ ] Black [ ] White Ethnic Origin ______________________ Address: ____________________________________ City __________________ State ______ Zip Code _________ Tel. No. ( )____ - ____ Alternate No.( )____ - _____ Name and Relation of Contact Person _____________ Does the person who you are filing against know this address? [ ] yes [ ] no Employer _______________________________________________________________________________________ Employer’s address _______________________________________________________________________________ Telephone Number ( ) __________ - ____________ Ext ________ Does the person who you are filing against know where you work? [ ] yes [ ] no Is the person you are filing against aware of another place you frequent? [ ] yes [ ] no Name of Place _________________________________ Address __________________________________________ What is your relationship to the person who you are filing against? [ ] Married [ ] Divorced [ ] Dating, if yes, how long? ______________ [ ] Boyfriend [ ] Former Boyfriend [ ] Intimate Partner [ ] Girlfriend [ ] Former Girlfriend [ ] Other, please specify: _________________ [ ] Roommate [ ] Neighbor Do you or have you ever lived with the person you are filing against? [ ] yes [ ] no Are you currently living with the person you are filing against? [ ] yes [ ] no If yes, do you have an alternative place to stay tonight? [ ] yes [ ] no Are you requesting the exclusive use of the dwelling where you are/were living with the person that you are filing against? [ ] yes [ ] no Are there any children in common with the person you are filing against? [ ] yes [ ] no Children’s Name 1. _________________________________________ Date of Birth 1.______________________________________________ 2. _________________________________________ 2. ______________________________________________ 3. _________________________________________ 3. ______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com If yes, are the children currently residing or staying with the person you are filing against? [ ] yes [ ] no Do you fear that the respondent will abuse, remove or hide minor children? [ ] yes [ ] no Would your children be in danger if an Injunction for Protection is not issued today? [ ] yes [ ] no If yes, please explain. ______________________________________________________________________________________________ ________________________________________________________________________________________________ Are you a victim of: [ ] verbal abuse [ ] psychological abuse [ ] sexual abuse [ ] physical abuse [ ] stalking The last episode of abuse took place: [ ] This week [ ] Last week [ ] Six months ago [ ] One year ago [ ] A month ago [ ] Three months ago [ ] More than one year ago [ ] other ________________ Specific Date of the last incident: ___________________________ Briefly describe the last incident of physical abuse, sexual abuse or stalking: ______________________________________________________________________________________________ ________________________________________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________________________________________ In addition to filing for a restraining order, will you be in need of any other services? [ ] yes [ ] no Briefly describe any specific area in which you need service. ______________________________________________________________________________________________ ________________________________________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com The following information requested is for the person you are filing against: Name _______________________________________________________________________ [ ] Female [ ] Male Birth Date _______________________ Is the Respondent known by a nickname/alias? _________________________________________________________ Is this person under 18 years of age? [ ] yes [ ] no If yes, name of parent/guardian ________________________ Relationship to him/her________________________ Respondent’s Place of Birth _______________ Race [ ] Black [ ] White Ethnic Origin __________________ Address: ____________________________________ City __________________ State ______ Zip Code _________ Telephone Number ( ) __________ - ____________ Alternate Number ( ) __________ - ____________ What is a good time to find this person at home? ________________________________________________________ Is there any other address where the respondent can be served? __________________________________________ What is the best time to find the respondent at the address above? __________________________________________ Employer _______________________________________________________________________________________ Employer’s address _______________________________________________________________________________ Telephone Number ( ) __________ - ____________ Ext ________ Days off from work _______________________________ Work hours ______________________________________ Physical Description: Height ___ ft ___ in Weight ___ lbs Hair color ____________ Eye color ______________ Any distinguishing marks, scars or tattoos? [ ] yes [ ] no If yes, please identify one __________________________ Vehicle information: Year ________ Make ________ Model __________ Color _________ Does this person own, possess and/or is known to possess a firearm? [ ] yes [ ] no [ ] I don't know If yes, what type(s) ____________ Has the Respondent threatened to use it against you? [ ] yes [ ] no [ ] Is this person required to carry/use a firearm in the capacity of his/her job? [ ] yes [ ] no Does this person have a drug problem? [ ] yes [ ] no [ ] I don't know Does this person have an alcohol problem? [ ] yes [ ] no [ ] I don't know Does this person have a history of clinically diagnosed mental health problems? [ ] yes [ ] no [ ] I don't know Since when have you known this person (date)? __________________________ 06/21/07 American LegalNet, Inc. www.FormsWorkFlow.com