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 applyCheck NO to all that DO NOT applySelfOther household memberDate
YESNOA finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction
YESNOAbusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction
YESNOOther:
Button: Check BoxA(DCH)
Button: Check BoxB(DCH)
Button: Check BoxE(DCH)
Button: Check BoxI(DCH)
Button: Check BoxF(DCH)
Button: Check BoxJ(DCH)
Button: Check BoxC(DCH)
Button: Check BoxG(DCH)
Button: Check BoxK(DCH)
Button: Check BoxD(DCH)
Button: Check BoxH(DCH)
Button: Check BoxL(DCH)
DateA(PCRAHVForm)
Text Field: DateB(DCH)
Text Field: DateC(DCH)
Text Field: OtherA(DCH)
  1. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse:
  2. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse:
Text Field: Evaluations(DCH) (format: password)
  1. 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:
  2. 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(DCH) (format: password)
  1. 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:
  2. 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(DCH) (format: password)