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Domestic Violence Screening
Cheryl L. Miller, LLC is committed to the safety and privacy of its clients. We ask that you please complete this confidential domestic violence screening if you have been a victim of domestic, sexual or intimate partner abuse. Having a history of domestic violence will not prevent you from obtaining our services. All information is kept confidential.
Donated by Office of Dispute Resolution Services, Seventh Circuit of Missouri and the Association of Missouri Mediators
Are you fearful of the other parent/party for any reason?
Have you been threatened with harm in any way?
Have you been hit or physically forced?
Have you ever called the police?
Have you ever filed a request for a protective order?
Have you sought other help for yourself?
Is there a protection order or restraining order currently?
Have you been denied or threatened with denial of access to your child/children?
Do you have any concerns about your child/children’s emotional or physical safety?
Has DFS or the court ever been involved in an allegation of child abuse or neglect?
Are you afraid the other parent/party may physically harm you now?
Are you afraid the other parent/party may physically harm you now?
What concerns do you have about meeting with the other parent/party face to face?
Your answer
Do you have any concerns about your safety coming and going from a mediation/coaching session?
Do you believe you are able to negotiate with the other parent/party in a way that you can advocate for your interests and the best interests of the child?
Is there anything else you can think of that would make you feel safe and confident in mediation?
Your answer
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