DV LEAP APPLICATION FOR OTHER RESOURCES

FULL LEGAL FIRST NAME & LAST NAME

First Name

Last Name

PREFERRED NAME

(First Middle Last):

First Name

Last Name

HOW WOULD YOU LIKE TO BE ADDRESSED IN CORRESPONDENCE?

(Example: Jane, Jane Doe, Mr. Doe, Miss. Doe):

DATE OF BIRTH:

YYYY

GENDER/GENDER IDENTITY:

(Please note: This question is optional but must be asked for grant reporting purposes.)

SEXUAL ORIENTATION:

YOUR PRONOUNS:

RACE/ETHNICITY:

DID ANOTHER ORGANIZATION REFER YOU TO DV LEAP?

(If yes, please put the name of the organization here. If no, please write N/A.)

EMAIL ADDRESS:

(Please make sure your email is correct as our initial communication regarding this application will be by email.)

IS IT SAFE TO EMAIL?

PHONE NUMBER:

(Including Area Code)

(###)

###

####

IS IT SAFE TO CALL?

IS IT SAFE TO LEAVE A MESSAGE?

CURRENT MAILING ADDRESS:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

IS IT SAFE TO RECEIVE MAIL HERE?

ARE YOU REGISTERED IN THE "SAFE AT HOME" PROGRAM?

DO YOU IDENTIFY AS HAVING A DISABILITY?

IF YES, IS THERE ANYTHING DV LEAP SHOULD KNOW OR DO TO BEST SERVE YOU AND YOUR NEEDS?

IN WHAT LANGUAGE ARE YOU MORE COMFORTABLE COMMUNICATING?

ARE THERE ANY OTHER LANGUAGES YOU USE?

DO YOU HAVE A FEE WAIVER IN YOUR CASE?

PLEASE SELECT THE AVERAGE NUMBER OF PEOPLE LIVING IN YOUR HOUSEHOLD OVER THE PAST 12 MONTHS, AND INDICATE WHETHER YOUR ANNUAL GROSS (BEFORE TAXES) INCOME WAS ABOVE OR BELOW THE CORRESPONDING AMOUNT LISTED BELOW.

For grant reporting purposes, DV LEAP asks about income. This information is required but will NOT affect your eligibility for our services.

WHAT KIND OF ASSISTANCE ARE YOU SEEKING?

ARE YOU ALSO LOOKING FOR "RESEARCH/WRITTEN RESOURCES"? IF YES, PLEASE SELECT WHICH RESEARCH OR WRITTEN RESOURCES YOU'RE LOOKING FOR:

Parental Alienation Allegations

Litigation Abuse

Concerns About Abusers' Parenting

Effects of Domestic Violence on Children

Courts Not Believing Domestic Violence Survivors/Stereotypes of Survivors

Child Sexual Abuse

Other

STATE CASE IS LOCATED IN:

COUNTY THE CASE IS LOCATED IN:

CASE NUMBER:

TYPE OF CASE:

DO YOU HAVE A LAWYER REPRESENTING YOU?

LAWYER'S NAME:

LAWYER'S FIRM/ORGANIZATION:

LAWYER'S EMAIL ADDRESS:

LAWYER'S PHONE NUMBER:

(###)

###

####

OPPOSING PARTY'S LEGAL FIRST NAME & LAST NAME

(First Middle Last):

First Name

Last Name

OPPOSING PARTY'S DATE OF BIRTH:

YYYY

DID YOUR OPPOSING PARTY HAVE A LAWYER REPRESENTING THEM?

OPPOSING LAWYER'S NAME:

OPPOSING LAWYER'S FIRM/ORGANIZATION

HAVE YOU EXPERIENCED DOMESTIC VIOLENCE?

‍(Domestic violence can occur between two people who have or have had an intimate relationship or have a child in common or are closely related. Domestic violence can be physical, emotional, sexual or financial. It can happen once or more than once. It can happen recently or a long time ago. We understand that answering these questions may be difficult and thank you for responding.)

DID THE OPPOSING PARTY IN YOUR CASE COMMIT DOMESTIC VIOLENCE AGAINST YOU AND/OR YOUR CHILD(REN)?

IF YES, PLEASE DESCRIBE:

(Optional) - (150 Words):

IS THERE ANY OTHER INFORMATION ABOUT YOUR CASE OR YOUR SITUATION THAT YOU WANT TO SHARE WITH US?

(150 Words):