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The
Women's
Bar
Association
Restraining Order Intake Form
Contact 1
First Name
Last Name
Gender
Female
Male
Transgender
Other
Prefer Not to Say
Phone Number
Email
Case
Is the client currently represented by an attorney? If yes, what is the name of the attorney?
Safe Mailing Address (CL)
City (CL)
State (CL)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Puerto Rico
Zipcode (CL)
Court County
Barnstable
Berkshire
Bristol
Dukes
Essex
Franklin
Hampden
Hampshire
Middlesex
Nantucket
Norfolk
Plymouth
Suffolk
Worcester
Safe to leave message
Yes
No
Race (CL)
African American/Black
Native American/Alaskan Native
Asian
Bi-racial
Native Hawaiian/Pacific Islander
Hispanic/Latino
Caucasian/White
Other
Preferred Language (CL)
Have you resided in Massachusetts for at least a year?
Yes
No
US Citizen? (CL)
Yes
No
If not a US citizen, explain (CL)
Do you have children?
Yes
No
Child 1 Name
Child 1 DOB
Child of OP? (Child 1)
Yes
No
Child 2 Name
Child 2 DOB
Child of OP? (Child 2)
Yes
No
Child 3 Name
Child 3 DOB
Child of OP? (Child 3)
Yes
No
Children notes
Currently employed? (CL)
Yes
No
If not currently employed, prior occupation (CL)
Employer (CL)
Occupation (CL)
Client Current Income
Is your income weekly, biweekly, monthly, or yearly?
Weekly
Biweekly
Monthly
Yearly
Client Current Income (Annualized)
Do you have any other income?
Yes
No
Other Income (TAFDC)
Other Income (SSI)
Other Income (SSDI)
Other Income (Alimony)
Other Income (Child Support)
Other Income (Rental Income)
Other Income (Other)
Is your Total Other Income weekly, biweekly, monthly, or yearly?
Weekly
Biweekly
Monthly
Yearly
Total Other Income (Annualized)
Family Size
Is there a marital home?
Yes
No
When was it bought?
Opposing Party Name
Address (Main) (OP)
Date of Birth (OP)
Language (OP)
US Citizen? (OP)
Yes
No
Unknown
If not a US citizen, explain (OP)
Living with OP now?
Yes
No
Have you lived with OP previously?
Yes
No
Were you married?
Yes
No
Where were you married?
Marriage date
Separation date
Divorce date
Have you experienced domestic abuse in your relationship?
Do you have an upcoming court date?
Yes
No
Date of hearing 1
Date of hearing 1: Date
Date of hearing 1: Time
What is your docket number?
Hearing Format
In person
Telephonic
Zoom
Hearing Dial-In Number or Zoom Link
Type of hearing
Are you calling for help on a restraining order?
Yes
No
Do you already have a restraining order?
Yes
No
Issuing court and Expiration Date
Has DCF ever been involved or are they currently involved?
Yes
No
Additional Info (Client)
Pronouns
She/her/hers
He/him/his
They/them/theirs
Not listed here
Prefer Not to Say
How much is the monthly mortgage payment?
How much equity in the home?
OP Pronouns
She/her/hers
He/him/his
They/them/theirs
Not listed here
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