Southern Midcoast CDVIP Men's Group Enrollment Form
To enroll in the Men’s DVIP Program, you must fill out THIS Intake form.
After we receive your intake form, you will get an email about Orientation.
You do NOT need to make any payments before you enroll.
Please only fill out this form if you live in Sagadahoc, Lincoln, or Eastern Cumberland (Brunswick or Harpswell) Counties.
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Today's Date *
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Full Name *
Date of Birth *
Email *
Phone Number *
Physical address *
Town or City *
Mailing address (if different than physical address)
Emergency Contact Name
Emergency Contact's relation to you?
Emergency Contact Phone Number
Race/Ethnicity  *
Required
Highest Level of Education *
Do you have any disabilities?   *
Employer (Company/business name and location.) *
About how much do you make each week? (Before taxes) *
Driver's License or State ID number *
 Make, model, year, and license plate # of all vehicles used by you:
 *
Under what charge have you been referred to our class? (Check all) *
Required
Referral Source *
Required
Probation Officer's Name
(If not on Probation, write "n/a")
 *
In which County did you go to court?
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Have you ever been arrested in the past for a Domestic Violence related crime? *
If yes, when? (Just the year is fine.)
If no, write "n/a"
 *
Have you ever been enrolled in a Program like this before? *
If yes, which program? 
If no, write "n/a"
 *
If yes, when? (Just the year is fine.)
If no, write "n/a"
 *
Have you ever been in trouble in the past for violating a PFA or No Contact Order? *
If yes, when? (Just the year is fine.)
If no, write "n/a"
 *
Is CPS involved in your case? *
If "yes" full name and email address of CPS Caseworker
(If no, write "n/a")
 *
Full name of the person listed as the victim in your crime *
Phone number of the person listed as the victim in your crime. (ONLY if known. Do not try to find this information if you don't know it already.)
Is there an active PFA or No Contact Order? *
Do you currently live with the person listed as the victim in your crime? *
Do you have children with this person? *
Current Partner's Full Name and phone number *
Do you currently live with your partner? *
Do you have any children? *
Describe your current custody arrangement- Do your children live with you? With a former partner? Both? (if you don't have children, write "n/a") *
Ages of children (if none, write "none") *
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