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Domestic Violence Intake

BASIC APPLICANT INFO

Applicant Full Name: Applicant Age: Applicant Date of Birth: Applicant Street Address: Applicant City: Applicant State: Applicant Zip Code: Applicant Phone: Applicant Fax: Applicant Email Address: Connection Location/Method: Case Number: County: Superior Court District: Court House Address: Court Department: Applicant Gender: Male Female

Applicant Height: Applicant Weight: Applicant Hair Color: Applicant Eye Color: Applicant Race: Applicant Children Street Address:
Applicant Children City: Applicant Children State: Applicant Children Zip Code:
Applicant Vehicle Type, Model, Year:

Applicant License Plate # and State:
Applicant Lawyer Full Name: State Bar Number: Firm Name: Case Type: Minors No Minors
Marriage / Domestic Partnership Date: Separation Date: Need Interpreter: Yes No
Specify Language:

PERSON PROTECTED FROM

Name of Person You Want Protection From:

Person Protected From Gender: Male Female

Person Protected From Age: Person Protected From Date of Birth:
Person Protected From Height: Person Protected From Weight: Person Protected From Hair Color: Person Protected From Eye Color: Person Protected From Race: Person Protected From Street Address:
Person Protected From City: Person Protected From State: Person Protected From Zip Code: Person Protected From Phone: Person Protected From Business Street Address:
Person Protected From Business City:
Person Protected From Business State:
Person Protected From Business Zip Code:
Person Protected From Business Phone:
Person Protected From Employer:
Person Protected From Occupation/Title:

Person Protected From Work Hours:
Person Protected From Driver License # and State:

Person Protected From License Plate # and State:

Person Protected From Vehicle Type, Model, Year:

Person Protected From, Description of Marks, Scars, or Tattoos:

Person Protected From Other Names Used:
Did Person have any guns or firearms?

FAMILY / HOUSEHOLD MEMBERS

Family/Household Member to Be Protected Name:
Family/Household Member Gender: Male Female

Family/Household Member Date of Birth:

Family/Household Member Age: Family/Household Member Race: Family/Household Member Relationship to Applicant:

Does member live with applicant? Yes No

Family/Household Member to Be Protected Name:
Family/Household Member Gender: Male Female

Family/Household Member Date of Birth:
Family/Household Member Age: Family/Household Member Race: Family/Household Member Relationship to Applicant:

Does member live with applicant? Yes No

Family/Household Member to Be Protected Name:
Family/Household Member Gender: Male Female

Family/Household Member Date of Birth: Family/Household Member Age: Family/Household Member Race: Family/Household Member Relationship to Applicant:

Does member live with applicant? Yes No

Describe Additional Protected People Below:

Family/Household members need an order for protection because:

RELATIONSHIP TO PERSON YOU WANT PROTECTION FROM

Now married or registered domestic partners Used to be married or registered domestic partners We live together. We used to live together. We are related by blood, marriage, or adoption.
Specify Relationship: Relationship Description:
We are dating or used to date, or we are or used to be engaged to be married. We are the parents together of a child or children under 18.
Our Child's Name: Date of Birth: Our Child's Name: Date of Birth: Our Child's Name: Date of Birth:
Describe Additional Children Below: We have signed a Voluntary Declaration of Paternity for our child or children.

OTHER ORDERS AND CASES

Other restraining / protective orders? No Yes

Order Date: Expiration Date: Any court cases with person to be protected from? : No Yes

Divorce, Nullity, Legal Separation:

County Filed: Year Filed: Case Number:

Civil Harassment:

County Filed: Year Filed: Case Number:

Domestic Violence:

County Filed: Year Filed: Case Number:

Criminal:

County Filed: Year Filed: Case Number:

Juvenile:

County Filed: Year Filed: Case Number:

Child Support:

County Filed: Year Filed: Case Number:

Parentage:

County Filed: Year Filed: Case Number:

Other: County Filed: Year Filed: Case Number:
Describe Additional Court Orders/Cases Below:

ORDERS YOU WANT

Personal Conduct Orders
Not to Harass, Attack, strike, threaten, assault, etc.
Not to contact, either directly or indirectly, in any way etc.

Stay Away Orders
I ask that the person to be protected from stays at least yards away from: Will person to be protected from be able to get to his home, school, job, workplace?
Yes No
If no, explain:

Move Out Order
I ask the court to order the person to not return to address:
I have the right to live at above address because:
Other Orders

Describe Additional Orders You Want Below:

GUNS, COMMUNICATIONS, AND ANIMALS

Does person own firearms or ammunition? Yes No I Don't Know

I ask for right to record communications violating judge's orders.
Care of Animals
      I ask that the person stays at least yards away from:
     I ask that the animals be with me because:

CHILD CUSTODY, VISITATION, and SUPPORT

Child Custody and Visitation I do not have a child custody/visitation order and want one.
I have a child custody/visitation order and want it changed. No Visitation Pending Hearing

Child Support I do not have a child support order and I want one.
I have a child support order and I want it changed. I now receive or have applied for TANF, Welfare, CalWORKS, or Medi-Cal.

PROPERTY, DEBT, AND SPOUSAL SUPPORT

Property Control
Give me control of:
Debt Payment Pay To: For: Amount: $: Due date: Describe Additional Debt Payments Below:

Property Restraint
Spousal Support

MOBILE DEVICE AND WIRELESS PHONE ACCOUNT

Rights to Mobile Device and Wireless Phone Account
Property Control
Give me control over phone#s:
My # Child # My # Child # My # Child #
Describe Additional Mobile Devices Below:

Debt Payment
I ask restrained person to make payments because: Name of wireless service provider: Amount $:
Due date:

Transfer of Wireless Phone Account

INSURANCE, FEES, COSTS, AND OTHER

Insurance
Lawyer's Fees and Costs
Payments for Costs and Services
Pay To: For: Amount: $: Pay To: For: Amount: $:
Batterer Intervention Program

SERVICE OF PROCESS

Time for Service
Explanation for less than 5 days service: Date and time informed:
How Informed:

By telephone to the the party By telephone to the attorney By personally informing: Other:
Attempts to Inform Included:
Did Not Give Notice Because:

Violence would reoccur. Other party would take children. Would make orders useless because:
Other reason:

DESCRIBE ABUSE (DECLARATION)

Describe all instances of abuse, including dates, individuals involved, details relating to the abuse, injuries, weapons used, whether the police came and issued an emergency protective order, and any other related information:

REVIEW HISTORY

COMMENTS FROM REVIEWER