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- RESTRAINING Orders or Domestic orders 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? NO YES TYPE:  OTHER PHYSICAL EMOTIONAL CHEMICAL IS A RESTRAINING ORDER OR A T.D.O. IN PLACE,    NO YES 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  SITUATION OF YOUR CHILDREN. click here for more domestic violence information not to be shared( CONFIDENTIAL) with other party) NOT PHYSICALLY VIOLENT 1. Discussed issues calmly NO YES 2. Sulked, refused to talk NO YES 3. Withdrew affection to punish   NO YES 4. Stomped out in order to punish    NO YES 5. Screamed, insulted or swore at the other NO YES 6. Threatened to leave the marriage   NO YES 7. Verbally pressured other to have sex   NO YES 8. Threatened punishment other than physical  (i.e., Withholding money, taking away children, having an affair) NO YES 9. Restricted physical or social movement NO YES 10.Intentionally interrupted the other’s sleeping  NO YES DIRECT THREATS OF VIOLENCE 11. Threatened to hit or throw something   NO YES 12. Threw, hit, or kicked something   NO YES 13. Drove recklessly to frighten others  NO YES 14. Directed anger at or threatened children NO YES 15. Directed anger at or threatened pets  NO YES 16. Threatened suicide NO YES SEVERE VIOLENCE 17. Threw something at   NO YES 18.  Pushed, carried, restrained, grabbed, NO YES 19. Slapped the other NO YES 20. Bit or scratched NO YES 21. Choked or strangled NO YES 22. Physically forced sex on NO YES 23. Punched  the other NO YES 24. Burned the other NO YES 25.Kicked the other  NO YES 26. Beat the other unconscious NO YES 27. Threatened with knife, gun or other NO YES 28. Used any weapon against NO YES

Email     ***REQUIRED FIELD***  

     FORM SUBMISSION