2. 2. Unless indicated by my checking the “YES” box next to an item below, I have checked the “NO” box to indicate that neither I nor any other member of my household have a history of violent or abusive conduct including the following:

Check YES to all that apply	Check NO to all that DO NOT apply		Self	Other household member	Date
YES	NO	A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction
YES	NO	Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction
YES	NO	Other:

YES□

NO□

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YES□

NO□

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Other:

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YES□

NO□

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3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse:
4. If any conviction above applies to a household member, not a party, state that person's name, date of birth, and relationship to the child:
5. If you are aware that the other party or members of the other party's household has or have a criminal record/abuse history, please explain: