Please select an option below that best reflects your proceedings*: I am currently living in London/Middlesex and Family Court proceedings will take place in London/MiddlesexI am NOT currently living London/Middlesex, but Family Court proceedings will be taking place in London/Middlesex, as that is the primary residence of the children/location of the marital home/etcOther, please specify below

Legal First Name*:

Legal Last Name*:

Preferred Name (first & last)*:

Date of Birth*:

Address (we do not mail anything to you)*:

City*:

Phone Number*:

Is it safe to call?*
YesNo

Is it safe to leave messages?*
YesNo

Email Address (if safe):

Family Court Support Workers can assist with the following, please select ALL that apply to you:
Parenting Time and/or Decision MakingChild SupportSpousal SupportDivision of PropertyDivorceOther (Please specify below) Other:

How did you find out about our services? Please select ONE option.*
V(WAP)Victim ServicesSexual Assault ServicesShelter/THSPCourt ServicesLegal ServicesIncome Support (ODSP/OW)Health Care Organization/CounsellingCommunity and Social Services including another Violence Against Women Organization/CAS etc)Self (You found our service by searching online, asking friends, etc)Internal Referral from AnovaPolice Services

Have you used Anova services in the past?*
YesNo

Your preferred language is*:

Will you require an interpreter?*:

Citizenship/Immigration Status*:
—Please choose an option—Canadian CitizenPermanent Resident/Landed ImmigrantStudent VisaRefugeeVisitor/No StatusI prefer not to answer

What gender do you identify as?*
FemaleMaleNon-Binary or Gender DiverseNot ListedPrefer not to say

Your preferred pronouns (optional)*:

Do you think of yourself as*:
—Please choose an option—Straight/HeterosexualLesbian/Gay/HomosexualBisexualAnother orientation not listedI prefer not to answer

Do you identify as First Nations, Métis, and/or Inuit?* Not ApplicableFirst NationsInuitMétis

If you identify as First Nations, Métis, and/or Inuit, please answer the following questions:Does Not ApplyStatus OFF ReserveSatus ON ReserveNon Status ON ReserveNon Status OFF Reserve

Which of the following best describes your racial or ethnic group?*
Black African (Afro-Caribbean, African Canadian descent)East/Southeast Asian (Chinese, Korean, Japanese, Taiwanese, Filipino, Vietnamese, Cambodian, Thai, Indonesian, other Southeast Asian)Indigenous/Native (noted above)Latino (Latin American, Hispanic descent)Middle Eastern (Arab, Persian, West Asian e.g., Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish)South Asian (East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean)White (European descent)Another race category not described aboveI prefer not to answer

Children Information

Child #1

First and Last Name:

Date of Birth:

Gender:
FemaleMaleNon-Binary or Gender-DiverseNot ListedPrefer Not to Say

Child #2

First and Last Name:

Date of Birth:

Gender: FemaleMaleNon-Binary or Gender-DiverseNot ListedPrefer Not to Say

Child #3

First and Last Name:

Date of Birth:

Gender:FemaleMaleNon-Binary or Gender-DiverseNot ListedPrefer Not to Say

Child #4

First and Last Name:

Date of Birth:

Gender:
FemaleMaleNon-Binary or Gender-DiverseNot ListedPrefer Not to Say

Child #5

First and Last Name:

Date of Birth:

Gender:
FemaleMaleNon-Binary or Gender-DiverseNot ListedPrefer Not to Say

Child #6

First and Last Name:

Date of Birth:

Gender:
FemaleMaleNon-Binary or Gender-DiverseNot ListedPrefer Not to Say

Opposing Party Information

Opposing Party First and Last Name*:

Opposing Party Address*:

Opposing Party City*:

What was/is their relationship to you*:
—Please choose an option—PartnerEx-PartnerBoyfriend/GirlfriendOther

What was/is your marital status with this person*:
—Please choose an option—MarriedCommon LawOther

Do you have an upcoming Family Court date? if yes, please list the location*:

Additional comments of information you think we need to know before your appointment:

Confidentiality Agreement

I understand that any and all information that I choose to share with Anova will be kept private and confidential and will not be shared with anyone without my written consent, with the following exceptions:

• If Anova has reason to believe that I am going to hurt myself or someone else, Anova has an obligation to call the London Police and connect me with the support I need.

• If Anova has reason to believe that a child under the age of sixteen is being abused or is at risk of being abused (including emotional harm which can be caused by witnessing domestic violence), Anova has a duty to report the information to the Children’s Aid Society.

• If the court requests a copy of your file, Anova is obligated to provide them with a copy of the entire file or any part that they wish to have. Anova can also be asked to testify in your case.

I understand and agree*

I understand that the Family Court Support Worker Program provides general information and support only. The Family Court Support Worker Program is not intended to be, and should not be taken, as legal advice.

I understand and agree*