FVO-Get Started Step 1 of 17 5% This questionnaire will ask you some fairly personal and sensitive questions. These questions need to be asked and answered so that your application can be completed with the best information possible. This is your opportunity to tell your story to the decision maker, who will decide the outcome of your application. Remember not to overthink and just answer one question at a time. You'll receive your paperwork (draft) in word version by email so you can tidy it up later on.Legal Aid Family Violence Unit is available by phone on 6207 1874 or firstname.lastname@example.org to provide advice and representation to applicants for interim orders Tell us a bit about who needs to be protectedWho needs to be protected?* Me, no-one else My child/ren My child/ren and I Do you or your child/ren need an immediate (interim) Family Violence protection order?* Yes No Do you or the person(s) who need protection have a disability?* Yes No How many children need the protection of a Family Violence Order?* 1 2 3 4 Let's start with youWhat's your given name(s)?* What's your surname?* What's your date of birth?* What gender do you identify most with?* Female Male Non-binary Your email address*If you believe or suspect that the person who need protection from may have access to this email address, you may want to consider creating a new email account and address altogether, or insert another email address of someone you trust What's your home address? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Is your address to be kept confidential or can it be shared with the respondent?* My address MUST remain confidential This address can be shared with the respondent What's your best contact telephone number?*What's another good contact phone number to be able to contact you?Eg. home, workIf there is any address where you may be contacted at, please provide details belowWhat's your occupation?* What's your first language?* How well do you speak English?*WellModerately wellPoorlyNot at allHow well do you read English?*WellModerately wellPoorlyNot at all Child/ren needing protectionChild 1: Their full name First Last Child 1: What's their date of birth? Child 2: Their full name First Last Child 2: What's their date of birth? Child 3: Their full name First Last Child 3: What's their date of birth? Child 4: Their full name First Last Child 4: What's their date of birth? Tell us about the person causing harmWhat's this person's given name(s)?*Insert their full name. We'll call this person 'the respondent' in this form What is this person's last name?* What's your relationship with the respondent?*(The respondent) We are married/divorced We are in a romantic relationship together We were in a romantic relationship If the respondent has any previous names, please list theseWhat's their date of birth?*(The respondent) What gender does the respondent identify most with?* Female Male Non-binary What's their address?*(The respondent's address) Street Address City State / Province / Region ZIP / Postal Code What's the respondent's best contact telephone number?*Is there another phone number for the respondent?Eg. work or homeWhat's the respondent's email address? Provide any other contact information that you may have for the respondentEg. other addresses, emails and phone numbersWhat does the respondent do for work?* How tall are they approximately?*(cm) How much do they weigh approximately?*(kg) How would you describe their build?*Lean, skinny, muscular, athletic, slender, overweight, obese What's their hair colour?* What's their eye colour? Describe any distinguishing features or marks/dress/tattoos/piercings/facial hairWhat's the respondent's first language?* How well does the respondent speak English?*WellModerately wellPoorlyNot at allHow well does the respondent read English?*WellModerately wellPoorlyNot at allWhat's the make & model of the respondent's car they drive? What type of car is it? What's its colour? What's the vehicle registration (if known)? What State or Territory is the car registered in? Provide as much information as you can that may help police to find, identify and serve your application on the respondentConsider listing places they regularly visit (gyms, cafes, restaurants, friends' homes), regular activities and identify any health conditions or disabilities that the respondent hasDo you think that the respondent will try to avoid being served with the family violence order?* Yes, probably Yes, maybe No, it's unlikely they'll try to avoid service Other ongoing casesAre there any parenting orders or plans or current proceedings involving the respondent and you/the other people named who need protection?*Tick which of the applyI'm unsureNot applicableThere are parenting orders in placeThere is a Parenting Plan in placeThere are court proceedings between the respondent and I about family law mattersPlease note that you'll need to provide a copy of the documents relating to this when you submit this Application. What's the next court date?*(if applicable) If there are any other court or tribunal orders about yourself, the people you've named who need protection from the respondent, please provide additional informationExamples include care and protection orders, mental health orders, family or personal violence orders, remand orders, detention orders or good behaviour orders. What's been happening?To help the decision maker understand why an immediate Family Violence Protection needs to be issued, some detail now needs to be provided. This is where you can tell your story, your narrative about what's happened and what you've experienced. Briefly explain what's happened to you or your children that has led you/them to need immediate protection from the person named (the respondent)*Is there a need to prevent substantial damage to your or your child/ren's property from the other person?* Yes or maybe No How has the respondent physically touched/hurt you/the person(s) needing protection?*eg. hitting, choking, punching, slapping Yes No Has the respondent ever been sexually violent or sexually abusive towards you or the person(s) in need of protection?*eg. pressure to participate in sexual, intimacy, unwanted sexual physical touch Yes No Has the respondent ever been emotionally abusive towards you or the person(s) in need of protection?*eg. insults, put downs, coercive manipulative behaviours Yes No Has the respondent been financially abusive?*eg. limiting access to money,=, controlling or monitoring spending, incurring debts in your name Yes No Has the respondent behaved aggressively towards you or the person(s) in need of protection?*eg. property damage, slamming doors/cupboards, punching walls Yes No Has the respondent ever behaved in an intimidating way or threatened you or the other people in need of protecting?*threats to damage property, harm you or someone else or a pet, yelling/screaming, standing over you during conflict or other, threats to self harm Yes No Has the respondent sexually harassed you or the person(s) needing protecting?* Yes there have been instances No/I'm unsure Has the respondent ever stalked or followed you?*eg. tracking devices, recordings (video/voice) Yes, I believe so Not to my knowledge Has the respondent ever verbally abused you or the person(s) need protection?*eg. put downs, insults, demeaning comments, gas lighting, Yes I don't necessarily 100% identify with this having happened In sentence form, what's prompted you to apply for protection?*"I am applying for this family violence order because…"When did this most recent incident occur?*If you can, provide an approximate month and year In sentence form, please tell us what happened*Where were you at the time? Do you know if the police were called?* Yes, the police were called I don't know No, not to my knowledge What was the police incident number for this occasion?If the police were called and they came, they will usually leave their card with an "incident number". Do you know if the police charged the respondent with any criminal offences for the most recent event where the police were called?* Yes No I'm not sure You can provide additional information about previous incidents concerning the respondent's behaviour towards you or the other people named who need protection to support your application. What would be your preference?* I want/need to provide additional information about their past behaviour I'm not sure, maybe. I'll include extra information now and decide later on whether I want to include or exclude it before I submit it properly No, I don't want to. I want to rely on the recent event only In sentence form, please tell us what happenedIt can be a good idea to include dates (or approximate), where this event(s) happened and specific detailsIs the respondent out on bail?* Yes No I'm not sure This next part is about providing some extra information that relates to other red flags that the decision maker needs to be aware of when considering your application. Does the respondent own a gun or have a gun licence?* Yes No Unsure They don't own a gun or have a gun licence, but they have access to guns Have there been any other previous family violence orders made between you/the person(s) needing protection who are named as part of this application, and the respondent—anywhere in Australia or New Zealand?* Yes No I'm not sure Is the Order current?* Yes No I don't know If you can, provide details about the Order if you know details for a fact. Alternatively, you can provide a copy of the Order to the Court if you have oneDo you know if the respondent has breached any family violence order?* Yes No I'm not sure What happened? This next question is a really important one to answer as honestly as you can. Has the respondent ever put their hands around your neck, attempt to choke or strangle you or caused you to lose consciousness?* Yes No Living arrangements & housingDoes the respondent know where you or your child/ren live?* Yes No In order to protect yourself or the other person(s) named in this application, do you need for an order to be made excluding the respondent from where they normally live?* Yes No If an order were made to exclude the respondent from where they normally live, would they have somewhere else to live?*Consider if they've got friends, family or have the money to rent or live elsewhere Yes No Do you and/or the person(s) who need protection have somewhere else you can live?* Yes No Not really, only short term If an order were made for you or the respondent to find somewhere else to live, how long do you think you/the respondent need in order to find somewhere else to live?* Is the respondent a child (ie. under 18 years)?* Yes No Does the respondent need to be excluded from being where they normally receive care and protection in order for you/the other person(s) you've named to be protected from them?* Yes No Do you or any of the person(s) who you've named who need protection have a disability?* Yes No Does the respondent have somewhere else to live?* Yes No Do you/the other person(s) who you've named as needing protection have somewhere else where you can live?* Yes No If an order were made for you or the respondent to find somewhere else to live, how long do you think you/the respondent need in order to find somewhere else to live?* Going forward—what the order needs to cover & includeYou can apply to have this order last for up to two years (24 months). How long do you want it to last for?* Six months 12 months 18 months 24 months Longer than two years How long do you want to have this order in place for?* Help the decision maker understand why a protection order needs to be made for longer than the ordinary two years.*Provide some detail about any "special" or "exceptional circumstances" that exist. Home & WhereaboutsWould it be acceptable to you to allow the respondent to go to your home on one occasion with police, to collect/return belongings?* Yes No Would it be acceptable to you to allow the respondent to go to your home if it was in accordance with a Family Court Order or a Parenting Plan?* Yes No Would there be any occasions under which it would be acceptable to you for the respondent to go to your home?* Yes No When can the respondent go to your home?* Name your workplace and its address to prohibit the respondent from being on its premises*Do you want to include an exception to the respondent going to your workplace?* Yes No What would be the exception for the respondent to be permitted to go to your workplace?* Do you want to restrict the respondent from going somewhere where you're likely to be?*For example, your parents' home or the day care where your child/ren attends Yes No Insert the addresses/places where you're likely to be that you want the respondent to be restricted from going to*Do you want to include an exception allowing the respondent to go to any of these places?* Yes No What would be the exception?*Are there other particular places that the respondent needs to be restricted from going to in order to protect you/the other person(s) named?*eg. a school, day care Yes No What are the addresses for these places?If one of the places is a school, do you agree to an exception that the respondent can attend the school(s) if it's for a parent-teacher interview or other school events for the respondent's child/ren? Yes No Physical distanceHow far away from you must the respondent be at all times (in metres)?*eg. 15m Can the respondent come within this distance of you if an order or parenting plan made under the Family Law Act says so?* Yes No Can the respondent come within this distance of you if they're spending time with their child/ren in accordance with a Parenting Plan or family court order?* Yes No Can the respondent come within this distance of you if you agree to attend counselling/mediation?* Yes No Can the respondent come within this distance of you if the respondent's child/ren suffers an injury or illness and has to go to hospital?* Yes No Can the respondent come within this distance of you if attending a school event or extracurricular activity/performance/game?*eg. parent-teacher interview, school assembly Yes No Can the respondent come within this distance of you if you're at court?* Yes No How far away must the respondent stay then?* Communicating with one anotherIf you click yes to mediation/counselling, this does not mean that you have to attend mediation/counselling. However, it is an important exception to consider if you would like to try and discuss future steps through a third party such as a mediator or a counsellor.Do you want the respondent to be allowed to contact you by email for the purpose of proposing that you participate in counselling/mediation?* Yes No Do you want the respondent to be allowed to contact and communicate with you at mediation or counselling (with your consent)?* Yes No Do you want the respondent to be allowed to contact you via a solicitor?* Yes No Do you want the respondent to be allowed to contact you orders or a parenting plan made under the Family Law Act allow for it?* Yes No Do you want the respondent to be allowed to contact you in writing (including SMS or email) to discuss the respondent's child/ren—their welfare, safety and handover* Yes No Do you want the respondent to be allowed to contact you in writing (including SMS or email) to discuss the respondent's child/ren—their care arrangements?* Yes No Do you want the respondent to be allowed to contact you by email to communicate about the financial aspect of our separation/relationship* Yes No Personal belongingsList any property that you or your child/ren reasonably need to keep to stop the respondent from taking itEg. the car, which might be registered in the respondent's name but which you driveDoes the respondent have any property of yours or your child/ren's that needs to be returned to you?*It must be 'reasonable'. For example, medical history book(s), passport(s), licence(s), medical scripts, medications, breastfeeding pumps, computer Yes No List any property that the respondent has of yours or your child/ren's that you reasonably need?For example, car seat, medical history book(s), passport(s), licence(s), medical scripts, medications, computer, breastfeeding pumpDo you want the Court to direct the respondent to participate in counselling, training, mediation, rehabilitation or assessment that is reasonably likely reduce the risks of future family violence?* Yes No Information sharingDo you want the Court to send a copy of it to any school?* Yes No What's the name of the school(s)?* Do you want the Court to send a copy of it to any day care/preschool?* Yes No What's the name of the child care?* Do you want the Court to send a copy of it to Housing ACT?* Yes No Do you want the Court to send a copy of it to Child Protection authorities?* Yes No Do you want the Court to send a copy of it to the Family or Federal Circuit Court?* Yes No Which Registry do you want a copy of the Order sent to?*http://www.federalcircuitcourt.gov.au/wps/wcm/connect/fccweb/contact-us/locations One final questionFinish this sentence… "If a family violence protection order isn't made, then I fear that the respondent will engage in family violence behaviours because…*If an order protecting you from the respondent isn't made, what do you fear happening?