ALLEGATIONS OF:

Please check any reasons you believe your family was referred
to the SAFE Family Program, or, check concerns you may have.

  1. ____ Domestic Violence                                                                        
  2. ____ Abuse by partner or family
  3. ____ Mental health problems
  4. ____ Living conditions
  5. ____ Flight risk
  6. ____ Neglect
  7. ____ Sexual abuse of your child
  8. ____ Sexual abuse of another child
  9. ____ Inconsistent visits
  10. ____ Other
  11. ____ Reunification
  12. ____ Physical abuse of a child
  13. ____ Drug abuse
  14. ____ Alcohol abuse
  15. ____ CPS case open
  16. ____ Parenting skills
  17. ____ Incarcerated


       (Please provide copy of conditions.)






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PLEASE USE THE REMAINING PAGE TO WRITE A BRIEF FAMILY HISTORY THAT  PERTAINS TO
THE COURT'S ORDER FOR SUPERVISED VISITATION.  The SAFE Application and Agreement To
Participate can be printed so that you can initial each section, sign it, and bring it with you when you
come to our office for an interview.
Telephone: (713) 755-5625 FAX: (713) 755-8824

www.victimassistancecentre.com