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: | | | |
|---|
- Please list any evaluation, counseling or other treatment received following conviction or finding of abuse:
- Please list any evaluation, counseling or other treatment received following conviction or finding of abuse:
Text Field: Evaluations(PlCH) (format: password)
- 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:
- 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:
Text Field: ConvictionInfo(PlCH) (format: password)
- 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:
- 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:
Text Field: CriminalHistory(PlCH) (format: password)