Empowering Parents when Domestic Violence is Present
First Name
Last Name
Email
*
Phone
*
Address
City
State
Postal code
How many children do you have?
1
2
3
4
5
6
More than 6
What are the ages of your children?
Who do the children live with most of the time?
Mostly with me
Mostly with the other parent
Shared equally by both parents
Other
What is the relationship between you and your co-parent?
Never married to each other
Married to each other
Separated from each other
Divorced
Other
Do you consider yourself to be:
American Indian / Alaskan Native
Asian
Black / African American
Hispanic or Latino
Middle Eastern/North African
Native Hawaiian / Pacific Islander
White
Other
Child Support status: (check all that apply)
No child support has been ordered nor have I requested child support
Child support requested but not yet ordered
A child support order is presently in place
I am seeking to modify a child support order
Other
What is your current income?
Less than $10, 000
$10,000 - $19,000
$20,000-$29,000
$30, 000 - $39,000
$40,000 - $49,000
$50,000 - $59,000
$60,000 - $69,000
$70,000 - $79,000
$80,000 - $89,000
$90,000 and above
Other...
Program attendance was:
Voluntary
Mandatory
Were you referred / ordered to attend or view by a Judge or Magistrate for a court case? If yes, please indicate the court location:
Augusta
Bangor
Belfast
Biddeford
Bridgton
Calais
Caribou
Dover-Foxcroft
Ellsworth
Farmington
Fort Kent
Houlton
Lewiston
Lincoln
Machias
Millinocket
Newport
Portland
Presque Isle
Rockland
Rumford
Skowhegan
South Paris
Springvale
Waterville
West Bath
Wiscasset
York
Court outside of Maine
Other
Opt-In to Text to Receive Messages from Us.
Yes
No
At this time the program is offered ONLY online. Please check all that apply:
I would prefer to participate in person.
I would prefer to participate online using zoom.
I have no preference.
Complete Registration / Payment
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
