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
    

• Has there been a Protective Order in the past 3 years?  Yes _____No _____
  

• Are you currently on Probation/Parole?  Yes _____ No _____
  

       (Please provide copy of conditions.)

• Conviction for _________________________
  

• Are you under CPS or criminal investigation?  Yes _____ No _____
  

• Do you have a criminal case pending?  Yes _____ No _____
  

• If so, provide information on pending investigations or criminal charges:
  

_________________________________________________________________________________


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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