Pathways to Family Peace Videoconference Domestic Violence Program Client Form
Please answer all questions that are marked required. If you do not know the answer, please write not applicable.
Date this form is being completed: *
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Client Information
The questions below are for you to answer about yourself:
First and Last Name *
Middle Name
Mailing Street Address *
Mailing City, State, Zip *
Email Address *
Ethnicity/Race *
Date of Birth *
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Phone Number *
Are you currently on probation or parole? *
If you answered yes, for how long?
Pathways to Family Peace is required by statute in the state of Minnesota to contact all victims of clients who are court ordered to attend a domestic abuse program. Please provide the following information for that purpose:
Name of Victim: *
Phone Number for Victim: (last known)
Mailing Street Address for Victim: (last known)
Mailing City, State and Zip-code for Victim: (last known)
Further Questions
The questions below are for you to answer about yourself:
Please describe in detail the reason you were referred to this program: *
Have you attended a domestic violence program before? *
If you answered yes, when and where?
Have you been referred to a chemical dependency program in the past or are you currently enrolled in one? *
If you answered yes, when and where?
Do you have a history of mental illness or cognitive challenges that the group facilitators should be aware of? *
If you answered yes, please explain:
Are you employed? *
If you answered yes about being employed, please describe how many hours per week you work on an average and what a typical work week is for you. For example, do you work Monday-Friday, every other weekend, or 4 days on/4 days off?
Do you have children living in your home or biological children of your own? *
If you answered yes, how many children and do they live with you part-time or full-time?
Is there currently an order for protection (OFP), Domestic Abuse No Contact Order (DANCO) or any other court order in place restricting your contact with the victim? *
If you answered other, please explain the other type of court order in place:
Are you court ordered to our program or volunteering to participate? *
Which agency referred you?
Name and Position of Person Who Referred You: (person we will contact about your participation in the program)
Work Phone of Referral Agency:
E-mail address of Referral Agency:
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