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          Trained in   Collaborative Divorce sm  model                

 

 

SOMEDAY, MAYBE 

THERE WILL EXIST A WELL-INFORMED,  WELL-CONSIDERED, AND YET FERVENT PUBLIC CONVICTION THAT THE MOST DEADLY OF ALL POSSIBLE SINS IS THE  MUTILATION OF A CHILD’S SPIRIT.

  ERIK ERIKSON

DOMESTIC VIOLENCE
INTAKE FORM-

THIS FORM IS FOR PEOPLE WHO HAVE EXPERIENCED DOMESTIC VIOLENCE

In order to mediate issues when there has been abuse, the mediator 

MUST assess the level and potential of abuse and establish safety before issues can be mediated.

ONLY MEDIATORS CERTIFIED AND TRAINED IN DOMESTIC VIOLENCE MEDIATION MAY MEDIATE DOMESTIC VIOLENCE CASES.

IF VIOLENCE IS INDICATED THIS FORM MAY BE E-MAILED TO US BUT WE WILL NEED  TO SPEAK TO YOU  BEFORE WE CAN MEDIATE THIS CASE.

DOMESTIC VIOLENCE
INTAKE FORM-

IT IS VERY IMP0RTANT THAT YOUR MEDIATOR IS INFORMED OF THE ABOVE.   

PLEASE FILL OUT THE FOLLOWING INFORMATION SO YOUR MEDIATOR WILL BE BETTER ABLE TO ASSESS THE SITUATION OF YOUR CHILDREN.

WAS ABUSE PRESENT IN RELATIONSHIP?

TYPE: 

IS A RESTRAINING ORDER OR A T.D.O. IN PLACE,   

IF YES EXPLAIN

(CONFIDENTIAL-not to be shared with other party)

   

SPECTRUM OF VIOLENCE

IT IS VERY IMP0RTANT THAT YOUR MEDIATOR IS INFORMED OF THE ABOVE.   

PLEASE FILL OUT THE FOLLOWING INFORMATION SO YOUR MEDIATOR WILL BE BETTER ABLE TO ASSESS THE 

click here domestic vioilence informationfor more domestic violence information

not to be shared( CONFIDENTIAL) with other party)

1. Discussed issues calmly

2. Sulked, refused to talk

3. Withdrew affection to punish  

4. Stomped out in order to punish   

5. Screamed, insulted or swore at the other

6. Threatened to leave the marriage  

7. Verbally pressured other to have sex  

8. Threatened punishment other than physical  (i.e., Withholding money, taking away children, having an affair)

9. Restricted physical or social movement

10.Intentionally interrupted the other’s sleeping 

11. Threatened to hit or throw something  

12. Threw, hit, or kicked something  

13. Drove recklessly to frighten others 

14. Directed anger at or threatened children

15. Directed anger at or threatened pets 

16. Threatened suicide

17. Threw something at  

18.  Pushed, carried, restrained, grabbed,

19. Slapped the other

20. Bit or scratched

21. Choked or strangled

22. Physically forced sex on

23. Punched  the other

24. Burned the other

25.Kicked the other 

26. Beat the other unconscious

27. Threatened with knife, gun or other

28. Used any weapon against

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Thank you for taking the time to answer the questions . Now we can better assist any question that you may have and may be able to assist  any  additional information needed.

 

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Last modified: September 10, 2009 
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