Stalking/Domestic Violence/Sexual Assault OP Intake Form

ALERT : Before completing the Intake form, you MUST call our agency to speak to a Domestic Violence Advocate to discuss your case. The phone number to call is (901)-222-3950. If you meet the criteria to file an Order of Protection, you will be required to attend an in-person meeting to get sworn in to complete the process. This is highly important also, as you may be asked to participate in an in-person Danger Assessment if your case involves high -risk Intimate Partner violence.

PREFERRED NAME

GOVERNMENT NAME

ADDRESS

CITY

STATE

ZIP

GENDER

MALE

FEMALE

OTHER

Specify Other *

DATE OF BIRTH

Year

Month

Day

AGE

HOME PHONE

Is it safe for us to leave a message at this number?

YES

CELL PHONE

Is it safe for us to leave a message at this number?

YES

EMPLOYER

WORK HOURS

WORK ADDRESS

WORK PHONE

EMAIL ADDRESS

Is it safe for you to receive an email from us?

YES

INFORMATION ABOUT THE PERSON YOU ARE FILING AGAINST

NAME

ALIAS / ALSO KNOWN AS

ADDRESS

NOTE: the complete work or home address of the person you are filing against is needed, so that law enforcement can physically serve them with the necessary paperwork (notice for the Order of Protection Hearing).

CITY

STATE

ZIP

ALTERNATE ADDRESS

CITY

STATE

ZIP

GENDER

MALE

FEMALE

OTHER

Specify Other *

DATE OF BIRTH

Year

Month

Day

AGE

HOME PHONE

CELL PHONE

EMPLOYER

WORK HOURS

WORK ADDRESS

WORK PHONE

DESCRIPTION OF PERSON YOU ARE FILING AGAINST

HEIGHT

WEIGHT

HAIR COLOR

EYE COLOR

VISIBLE DISTINGUISHING FEATURES (SCARS, TATTOOS)

VEHICLE DESCRIPTION

COLOR

MAKE

MODEL

STATE

YEAR

LICENCE PLATE NUMBER

BEST TIME FOR SHERIFF TO SERVE PAPERWORK

HAS THIS PERSON EVER BEEN ARRESTED BEFORE?

YES

NOT SURE

INFORMATION ABOUT YOU (THE COMPLAINANT) AND WHAT HAPPENED (THE COMPLAINT)

WHAT IS THIS PERSON'S RELATIONSHIP TO YOU ?

CURRENT OR EX ?

CURRENT

DEFINE RELATIONSHIP

WHAT HAPPENED? *

STALKING/HARRASMENT

SEXUAL ASSAULT/SEXUAL VIOLENCE ONLY

DETAILS ABOUT WHAT HAPPENED

GIVE DATE, TIME & LOCATION THAT THE INCIDENT OCCURRED

DID THIS INCIDENT HAPPEN INSIDE SHELBY COUNTY?

YES

IF NO, WHERE DID THE INCIDENT OCCUR?

PLEASE BRIEFLY DESCRIBE WHAT HAPPENED

DID THE OTHER PERSON THREATEN TO HURT YOU OR THREATEN TO KILL YOU DURING ANY PHONE CALLS, TEXT MESSAGES, OR SOCIAL MEDIA MESSAGES/POSTS?

YES

HAVE YOU RECEIVED THREATS IN-PERSON BY PERSON YOU ARE FILING AGAINST?

YES

HOW MANY CALLS DID YOU RECEIVE WHICH HAD THREATS TO HURT OR KILL YOU?

WHAT WAS THE DATE OF THE MOST RECENT THREATENING CALL?

(If YOU DO NOT KNOW EXACT DATE, THE MONTH AND YEAR IS FINE)

DID THE OTHER PERSON SPEAK TO YOU AND/OR LEAVE A MESSAGE?

YES

DID YOU RECOGNIZE THE OTHER PERSON’S VOICE ON THESE CALLS?

YES

DID YOU RECEIVE THESE THREATENING CALLS/TEXTS AT HOME?

YES

DID YOU RECEIVE THESE THREATENING CALLS/TEXTS AT WORK?

YES

DID YOU RECEIVE THESE THREATENING CALLS/TEXTS ON YOUR CELL PHONE?

YES

DID YOU RECEIVE THESE THREATS ON YOUR EMAIL AND/OR YOUR SOCIAL MEDIA ACCOUNT(S)?

YES

DO YOU HAVE A LOG OF THE DATES AND TIMES OF THE INCIDENTS?

YES

DO YOU HAVE ANY WITNESSES WHO CAN ACCOMPANY YOU TO COURT?

YES

DID YOU FILE A POLICE REPORT?

YES

WAS ANY PROPERTY DAMAGED?

YES

IF SO WHAT?

WOULD YOU LIKE FOR THE PERSON TO BE PROHIBITED FROM CAUSING INTENTIONAL DAMAGE TO YOUR PROPERTY?

YES

WOULD YOU LIKE FOR THE PERSON TO BE PROHIBITED FROM INTERFERING WITH THE UTILITIES AT YOUR HOME?

YES

IF THE PERSON YOU ARE FILING AGAINST IS YOUR CELL PHONE ACCOUNT HOLDER, WOULD YOU LIKE THE BILL TO BE TRANSFERRED TO YOUR NAME?

YES

HAS THIS PERSON BEEN FOLLOWING YOU?

YES

HAS THIS PERSON BEEN COMING TO YOUR HOME OR PLACE OF EMPLOYMENT WITHOUT YOUR PERMISSION?

YES

HAS THIS PERSON BEEN DROPPING THINGS OFF AT YOUR PROPERTY THAT UPSETS YOU?

YES

HAS THIS PERSON BEEN CALLING YOU WITH THREATS?

YES

HAS THIS PERSON BEEN SENDING YOU THREATENING MESSAGES VIA TEXT/SOCIAL MEDIA OR EMAILS?

YES

DOES THIS PERSON HAVE AN ALCOHOL OR DRUG PROBLEM OR SUFFER FROM MENTAL HEALTH ISSUES?

YES

IF SO, DO YOU REQUEST THE OTHER PARTY BE REQUIRED TO ATTEND COUNSELING FOR DOMESTIC VIOLENCE/ANGER MANAGEMENT OR SUBSTANCE ABUSE (ALCOHOL AND/OR DRUG DEPENDENCY)?

YES

ARE THERE ANY COURT CASES PENDING IN WHICH YOU AND THIS PERSON ARE INVOLVED?

YES

TYPE

CASE #

COURT / DIVISION

DO YOU ALREADY HAVE AN ORDER OF PROTECTION AGAINST THIS PERSON?

YES

DOES THIS PERSON OWN OR POSSESS A FIREARM?

YES

HAS THIS PERSON’S ACTIONS CAUSED YOU TO FEEL TERRORIZED, FRIGHTENED, INTIMIDATED, THREATENED OR HARASSED?

YES

WOULD YOU LIKE TO SPEAK WITH AN ADVOCATE ABOUT PREPARING FOR YOUR COURT HEARING?

YES

WERE YOU INJURED?

YES

TYPE OF INJURY?

IF YOU WERE, DID YOU RECEIVE MEDICAL TREATMENT?

YES

WHEN

Year

Month

Day

WHERE

DID YOU RECEIVE INFORMATION ABOUT THE VICTIM COMPENSATION INJURY FUND?

YES

IF NO, WOULD YOU LIKE TO KNOW ABOUT THIS SERVICE?

YES

WAS A POLICE REPORT TAKEN AND FILED?

YES

WAS ANYONE ARRESTED BY THE POLICE ON THIS INCIDENT?

YES

IF SO, WHO WAS ARRESTED AND WHAT WAS THE CHARGE?

WERE ANY WEAPONS USED?

YES

IF SO, WHAT TYPE OF WEAPON?

DOES THE OTHER PARTY OWN OR POSSESS A FIREARM?

YES

IF YES, HAS THE OTHER PARTY USED IT, OR THREATENED TO USE IT, AGAINST YOU?

YES

HAVE YOU EVER LIVED WITH THE OTHER PARTY?

YES

DO YOU AND THE OTHER PARTY CURRENTLY LIVE TOGETHER?

YES

IF YOU LIVE TOGETHER, WHOSE NAME IS ON THE LEASE OR MORTGAGE FOR HOUSE OR APARTMENT?

WOULD YOU LIKE THE OTHER PERSON TO LEAVE YOUR SHARED RESIDENCE?

YES

HAS THIS PERSON BEEN ABUSIVE TOWARDS YOU IN THE PAST?

YES

IF YES, BRIEFLY DESCRIBE PAST INCIDENT(S):

DOES THIS PERSON HAVE AN ALCOHOL OR DRUG PROBLEM OR SUFFER FROM ANY MENTAL HEALTH ISSUES?

YES

IF SO, DO YOU REQUEST THE OTHER PARTY BE REQUIRED TO ATTEND COUNSELING FOR DOMESTIC VIOLENCE/ANGER MANAGEMENT OR SUBSTANCE ABUSE (ALCOHOL AND/OR DRUG DEPENDENCY)?

YES

IF MARRIED, HAS A DIVORCE BEEN FILED?

YES

DOES NOT APPLY

ARE THERE ANY COURT CASES PENDING IN WHICH YOU AND THE DEFENDANT ARE INVOLVED?

YES

TYPE

CASE #

COURT / DIVISION

DO YOU HAVE A CURRENT ORDER OF PROTECTION ON THIS PERSON?

YES

DO YOU AND THIS PERSON HAVE MINOR CHILDREN TOGETHER?

YES

WERE THE CHILDREN INJURED IN THE INCIDENT (S) THAT HAVE LED YOU TO FILE FOR AN ORDER OF PROTECTION?

YES

IF SO, PLEASE LIST THEIR FULL NAME(S) AND AGE(S) BELOW: FULL NAME(S): AGE(S): BRIEF DESCRIPTION OF WHAT OCCURRED:

HAVE YOUR CHILDREN EVER WITNESSED DOMESTIC VIOLENCE BETWEEN YOU AND THE OTHER PERSON?

YES

DOES NOT APPLY

WOULD YOU LIKE THE CHILDREN NAMED ABOVE ON THE ORDER OF PROTECTION?

YES

DOES NOT APPLY

WOULD YOU LIKE THE PERSON YOU’RE FILING AGAINST TO GIVE YOU CUSTODY AND CONTROL OF ANY ANIMAL OWNED, POSSESSED, LEASED, KEPT OR HELD BY YOU, THE PERSON FILING AGAINST OR THE CHILDREN LISTED ABOVE?

YES

WOULD YOU LIKE TO RECEIVE INFORMATION REGARDING COUNSELING OR SUPPORT GROUP SERVICES FOR YOU OR YOUR CHILDREN?

YES

DO YOU HAVE A SAFE PLACE TO STAY?

YES

WOULD YOU LIKE TO SPEAK WITH AN ADVOCATE ABOUT PREPARING FOR YOUR COURT HEARING?

YES

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Shelby County Crime Victims & Rape Crisis Center

Translator

Stalking/Domestic Violence/Sexual Assault OP Intake Form