Domestic abuse referral form

Your name

Your email

Full address

Names and dates of birth of all children living in family home

Safe telephone number

When would be the best time to contact you?
 morning afternoon evening

If you are the Applicant please state the type of order sought (see below) and provide brief details of why you are seeking the order(s). If you are the Respondent state what order is being sought against you and your grounds for objecting.

Possible Court Orders

Non Molestation Order
This is an order preventing not only violence but any form of harassment eg abusive language, pestering; humiliating. And can be direct or indirect ie text, facebook.
It is possible to get this order without first having to notify the other party eg where you consider that if s/he knows ahead of time that you are applying to the court you will suffer violence

Occupation Order
This is an order requiring the other party to leave the family home and/or to allow you to return to it
This is an order which normally requires proof of violence and is seldom made without first giving notice to the other party.

Brief Details of recent and previous two incidents (if applicable) with dates and times.
(normally incidents within last THREE months only unless there have been previous convictions for violence or other serious incidents)
Please note any matters carried out within the sight or hearing or presence of the children.

Full name, date of birth and address of Perpetrator

Is family home owned or rented?
 owned rented

If owned names and address of mortgagee. If rented names and address of landlord

Is home in your name, perpetrator’s name or joint names?
 mine perpetrator's joint

Have you applied for public funding (legal aid) so that you may be assisted by a solicitor? If so, what is the current status?
 yes no

Have you sought advice from another organisation (e.g. solicitors, law centres, CAB)?
 yes no

If so please state the organisation with approximate dates

Any Particular Degree of Urgency?

Please provide brief details of your financial position