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2. DOMESTIC VIOLENCE SCREENING
4. Docket Number (Case Number)
5. Judge
7. Your name*
   First, middle and last name
9. Name of other party on case*

   First and last name

11. Date*
    Date
13. Our goal is to provide a safe environment for families with a friend of the court case. We often meet with both parents. However, there are times bringing both parents together may not be appropriate. Your answers to the following questions will help us determine whether both parents can meet together in a safe environment. The information you provide can only be viewed by judges, referees, and friend of the court staff. It cannot be viewed by the other parent or his or her attorney, and it cannot be used in any court proceedings. Please answer the following questions to the best of your ability.
15. 1. Do you feel safe around the other parent?*

    1. Yes
    2. No
17. Please Explain:
19. 2. Is there currently or has there ever been a personal protection order or a no contact order limiting contact between you and the other parent?*

    1. Yes
    2. No
21. Please explain including when and where:
23. 3. Is there currently or has there ever been a personal protection order or a no contact order issued against the other parent or you by someone else?*

    1. Yes
    2. No
    3. Unknown about other parent
25. Please explain including when and where:
27. 4. Have the police been called to your home or involved in any incidents in the past year between you and the other parent?*

    1. Yes
    2. No
29. Please Describe:
31. 5. Have you or the other parent been arrested in the past year?*

    1. Yes
    2. No
33. Please describe:
35. 6. Have you ever felt unsafe around the other parent?*

    1. Yes
    2. No
37. Please Explain:
39. 7. Is there currently or has there ever been child protective (abuse/neglect) actions involving you and/or the other parent in Michigan or any other state or country?*

    1. Yes
    2. No
    3. Unknown about other parent
41. Please Explain:
43. 8. Do you have any concerns about discussing issues regarding your children in front of the other parent?*

    1. Yes
    2. No
45. Please explain
47. 9. Are you afraid that the other parent will harm or pressure you during or after a friend of the court meeting because of what is discussed in the meeting?*

    1. Yes
    2. No
49. Please Explain:
51. 10. Do you have any concerns about sitting in the same room with the other parent?*

    1. Yes
    2. No
53. Please Explain:
55. 11. Do you think you can speak up for yourself in a friend of the court meeting if the other parent is also present?*

    1. Yes
    2. No
57. Please Explain:
59. 12. Has the other parent ever made you feel threatened or harassed?*

    1. Yes
    2. No
61. Please Explain:
63. 13. Is there anything not already discussed that would prevent you from participating in a friend of the court meeting with the other parent?*

    1. Yes
    2. No
65. Please Explain:
67. Your safety is important, so please contact us to discuss any safety concerns you may have and what can be done to address your concerns.
69. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
71. Electronic Signature*
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field