FM-1076 REV 11/25/08 Page 1 of 4
Family Court Services
201 North First Street
San Jos
é, California 95113
(408) 534-5760
(Physical, Emotional, Verbal and Economic Abuse)
Name: Other Parent’s Name:
(Please Print)
Case Number:
FCS Number:
The following information will be used by Family Court Services in assessing any history of domestic violence and/or
emotional abuse in the family so that: 1) mediations and investigations may be conducted in the most appropriate
manner; 2) any recommendations are based on an accurate understanding of the domestic violence issues, and 3)
any agreements or recommendations include appropriate safety considerations.
The information you provide on this form is NOT confidential. Family Court Services may disclose
any of the information to third parties, including law enforcement or child welfare agencies under
appropriate circumstances, and the information could be used against you in a criminal
prosecution. You may want to consult with your attorney before submitting this form.
The other parent, at his or her request and with a signed Protective Order, will be provided a copy of
your responses and will have the opportunity to respond.
Any information you do provide must be true and accurate and not intended to mislead.
You DO NOT have to answer questions if you believe that by doing so, you may endanger yourself
or your children.
This form is not required. If you elect not to answer some or any of the questions, your failure to
answer will NOT be used against you by Family Court Services.
Check here if, for any reason, you need help in completing this form.
Check here if you DO NOT wish to complete this form.
Date of Parties’ Separation:
Length of Relationship or Marriage:
Has there been a Family Code §3044 Finding?
Please complete & return this form to Family Court Services before your next appointment.
Source: Adapted by Family Court Services, 2007 from Danger Assessment Scale 2001 by Jackie Campbell.)
Yes No N/A
1. Has the other parent been violent toward a previous partner? (If you
were his/her 1
relationship, check N/A.)
2. Has the physical violence increased in severity or frequency over the
past year before you decided to leave him her/her?
3. Has he/she ever used a weapon against you or threatened you with a
4. Did he/she ever try to choke you (strangle/cut off air with hands or object
around neck)?
5. Does he/she own/have access to a gun?
6. Has he/she ever forced you to have sex when you did not wish to do so?
7. Doe he/she use drugs? By drugs, we mean “uppers” or amphetamines,
speed, angel dust, cocaine, “crack,” street drugs or mixture?
8. Has he/she threatened to kill you or the children and/or do you believe
he/she is capable of killing you or the children?
9. Does he/she get intoxicated/drunk every day or almost every day?
(frequency of drinking) Or d
oes he/she get intoxicated every time
he/she drinks (quantity of drinking)?
10. Did he/she control most of all of your daily activities? For instance:
isolate you,
tell you with whom you can be friends, who you can see,
how much money you could
use, if you could work, when you could
take the car, etc.
11. Have you ever been beaten by him/her while you were pregnant. (If
never been pregnant, check N/A)
12. Is he/she violently and constantly jealous of you? (For instance, does
he/she say, “If I can’t have you, no one can.”)
13. Have YOU ever threatened or tried to commit suicide?
14. Has the OTHER PARENT ever threatened or tried to commit suicide?
15. Does he/she threaten to harm your children?
16. Do you have a child that is not the child of your partner?
17. Is the other parent unemployed?
18. Have you left him/her during the past year? (If you have never lived with
him/her, check N/A)
19. Are you in the process of divorcing him/her? (If you were never married
to him/her check N/A)
20. Do you currently have another intimate partner?
21. Does the other parent follow or spy on you, leave threatening notes,
destroy your property, or call you when you don’t want him/her to do so
22. Has the other parent ever violated a protective order or been arrested for
charges related to domestic violence, assault, alcohol, illicit drugs? If
yes, briefly explain.
23. Do you currently fear for your safety or your child's safety or have
any concerns for future safety? If yes, please explain.
Other Comments:
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Please put a check mark in the correct box. If the OTHER PARENT did or ever threatened to do the
violence, mark the column on the LEFT side of the page. If YOU did or ever threatened or were
violent, mark the column on the RIGHT side of the page. Please explain where necessary.
I. Level of Physical Violence:
Other Parent You
1 - 3 Times
4 or More
1- 3 Times
4 or More
Pushing, carrying, shoving, grabbing, or restraining you
Attempted or actual slapping with an open hand
Attempted or actual hitting with a closed hand or fist
Pulling your hair
Biting or kicking you
Hitting you in the head, face, breasts or genital area
Attempted or actual choking, strangulation or
Tried to hit you with, or throw you out of, a car or truck
Burned you
Drove recklessly to scare you
Threw objects at you
Raped you or forced you to have sex
Abuse to pets
Destruction of property
Cruel or sadistic infliction of pain
Kidnapped you and/or your child
Breaking into and entering your residence
Child abuse (describe)
Other (describe)
II. Level of Emotional, Verbal & Economic Abuse:
Other Parent You
1- 3 Times
4 or More
1 - 3 Times
4 or More
Humiliating, embarrassing, “putting you down” or doing
so to the other parent
Blaming all problems on you or you blaming the other
Interrupting other parent’s eating or sleeping
Not permitting you or you not permitting the other parent
to go anywhere by himself/ herself
Punishing for contacts with others
Demands constant knowledge of whereabouts
Making automobile not work, withholding car keys
Making telephone not work
Threatening family and friends
Were your children exposed to violence or to threats?
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Falsely accusing of being sexually unfaithful
Other Parent You
1-3 Times
4 or More
1-3 Times
4 or More
Using the children against you or kept you from seeing
them or so doing so to the other parent
Making an unreasonable number of phone calls to you
or you doing so to the other parent
Refusing to leave the other parent’s home or workplace
Following you or you following the other parent
Destroying or stealing your immigration papers, refusing
to help you gain legal status, calling you names like
“illegal,” threatening to have you deported, or reporting
you to immigration
Do you need referrals for shelter, counseling or other services? If yes, please name the services:
III. Are you in a current relationship that has any of the above elements of domestic violence?
(Please comment)
IV. Have you been in a relationship in the past that has any of the above elements of domestic violence?
(Please comment)
V. How were your children affected by any of the above?
When seen in mediation or emergency screening, or evaluation, I wish to be seen:
YES NO Separately, without the other parent in the room with me.
YES NO Together with the other parent in the same room with me.
(FCS w
ill ask you to submit a written consent form.)
YES NO Do you have a current protective order against the other parent?
RIGHT TO A SUPPORT PERSON: If you have a current protective order against the other parent, the law
gives you the right to have a support person of your choice (not your attorney) with you in mediation
You also may
be permitted to have a support person with you in a screening, assessment or evaluation
but only if the investigator believes it will not interfere with the investigation.
If you have a current protective order against the other parent, do you wish to have a support person with
you in session?
I declare, under penalty of perjury, that the information on this form is true and correct.
Date: Signature:
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