LEGAL FIRST NAME & LAST NAME
First Name
Last Name
Middle Name
PREFERRED NAME
First Name
Last Name
HOW WOULD YOU LIKE TO BE ADDRESSED IN CORRESPONDENCE? (Example: Jane, Jane Doe, Mr. Doe, Miss. Doe)
DATE OF BIRTH:
*
MM
DD
YYYY
ETHNICITY - Do you identify as Hispanic or Latin(o/a/e/x)?
Yes
No
Prefer not to answer
Unknown
RACE - Select all that apply
GENDER/GENDER IDENTITY: (Please note: This question is optional but must be asked for grant reporting purposes.)
SEXUAL ORIENTATION: (Please note: This question is optional but must be asked for grant reporting purposes.)
YOUR PRONOUNS:
*
She/Her/Hers
He/His/Him
They/Them/Theirs
Prefer Not To Say
Other
IS IT SAFE TO EMAIL?
*
Yes
No
PHONE NUMBER
*
(Including Area Code)
(###)
###
####
IS IT SAFE TO CALL?
*
Yes
No
IS IT SAFE TO LEAVE A MESSAGE?
*
Yes
No
CURRENT MAILING ADDRESS:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
IS IT SAFE TO RECEIVE MAIL HERE?
*
Yes
No
ARE YOU REGISTERED IN THE "SAFE AT HOME" PROGRAM?
Yes
No
DO YOU IDENTIFY AS HAVING A DISABILITY?
Yes
No
IF YES, IS THERE ANYTHING DV LEAP SHOULD KNOW OR DO TO BEST SERVE YOU AND YOUR NEEDS?
IN WHAT LANGUAGE ARE YOU MOST COMFORTABLE COMMUNICATING?
*
ARE THERE ANY OTHER LANGUAGES YOU USE?
DO YOU HAVE A FEE WAIVER IN YOUR CASE?
*
Yes
No
Not Sure
ARE YOU SEEKING REPRESENTATION TO APPEAL THIS ORDER?
*
HAS SOMEONE FILED AN APPEAL AGAINST YOU, AND YOU ARE SEEKING REPRESENTATION?
*
ARE YOU SEEKING AN AMICUS BRIEF FOR YOUR APPEAL?
*
STATE CASE IS LOCATED IN:
*
CO
DC
FL
IL
MA
MD
MN
NY
OH
PA
TX
VA
Other
COUNTY THE CASE IS LOCATED IN:
*
CASE NUMBER:
TYPE OF CASE:
*
Child Custody
Child Custody & Divorce
Divorce
Protection Order
Other
DATE OF FINAL ORDER:
*
MM
DD
YYYY
DO YOU HAVE A PHYSICAL COPY OF THE FINAL ORDER?
*
Yes
No
Other
HOW MANY DAYS WAS YOUR TRIAL/HEARING THAT RESULTED IN THIS FINAL ORDER?
*
DO YOU HAVE WRITTEN TRANSCRIPTS FROM YOUR TRIAL?
*
Yes
No
Other
IF YOU ARE SEEKING AN AMICUS BRIEF, HOW WILL THE BRIEF HELP YOUR APPEAL AND/OR WHAT ISSUES DO YOU WANT IT TO ADDRESS?
HAVE YOU FILED A NOTICE OF APPEAL IN THIS CASE?
*
Yes
No
IF YES, WHAT DATE DID YOU FILE THE NOTICE OF APPEAL?
MM
DD
YYYY
IS THERE ANOTHER HEARING SCHEDULED IN THIS CASE [OR A RELATED CASE]?
Yes
No
Other
IF YES, WHAT IS THE DATE OF THE NEXT HEARING?
MM
DD
YYYY
DID A LAWYER REPRESENT YOU AT THE TRIAL RESULTING IN THE ORDER YOU WANT TO APPEAL/ IS BEING APPEALED AGAINST YOU?
*
Yes
No
IS THIS LAWYER STILL REPRESENTING YOU?
*
Yes
No
LAWYER'S NAME:
LAWYER'S FIRM/ORGANIZATION:
LAWYER'S EMAIL ADDRESS:
LAWYER'S PHONE NUMBER:
(Including Area Code)
(###)
###
####
DO YOU GIVE DV LEAP PERMISSION TO CONTACT YOUR LAWYER TO DISCUSS YOUR CASE?
*
Yes
No
DO YOU HAVE A LAWYER REPRESENTING YOU IN YOUR APPEAL?
*
Yes
No
OPPOSING PARTY'S LEGAL FIRST NAME & LAST NAME
*
First Name
Last Name
Middle Name
OPPOSING PARTY'S DATE OF BIRTH:
*
MM
DD
YYYY
DID YOUR OPPOSING PARTY HAVE A LAWYER REPRESENTING THEM IN THE ORDER YOU WANT TO APPEAL/ IS BEING APPEALED AGAINST YOU?
*
Yes
No
Not Sure
OPPOSING LAWYER'S NAME:
OPPOSING LAWYER'S FIRM/ORGANIZATION
DID THE OPPOSING PARTY IN YOUR CASE COMMIT DOMESTIC VIOLENCE, SEXUAL ASSAULT, HARASSMENT, STALKING, OR DATING ABUSE AGAINST YOU AND/OR YOUR CHILD(REN)?
*
Yes
No
Not Sure
IF YES, PLEASE DESCRIBE:
(Optional) - (150 Words):
DID A COURT FIND THAT YOUR OPPOSING PARTY COMMITTED DOMESTIC VIOLENCE AGAINST YOU AND/OR YOUR CHILD(REN)?
*
Yes
No
Not Sure
WE UNDERSTAND THAT SOME PEOPLE WHO WERE ABUSED HAVE HAD PROTECTION ORDERS OR FINDINGS OF ABUSE ISSUED AGAINST THEM. HAS THE OPPOSING PARTY ACCUSED YOU OF DOMESTIC VIOLENCE?
*
Yes
No
Not Sure
DID A COURT FIND THAT YOU COMMITTED DOMESTIC VIOLENCE?
*
Yes
No
Not Sure
IS THERE ANY OTHER INFORMATION ABOUT YOUR CASE OR YOUR SITUATION THAT YOU WANT TO SHARE WITH US?
(150 Words):
IS THERE ANYTHING WE NEED TO KNOW ABOUT YOUR CULTURE OR COMMUNITY THAT WOULD HELP US UNDERSTAND YOUR SITUATION?
(150 Words):
