Provide supplemental information when making or responding to allegations of harm and domestic violence

Published date21 March 2018
Subject MatterChildren Act forms
Allegations of harm and
domestic violence
(Supplemental information form)
This form cannot be used to make an application for a
court order. It must be sent to the court together with
the relevant application form.
To be completed by the court
The Family Court sitting at
Date issued
Case number
Order(s) applied for
Please read the notes at the end of this form before completing it.
If completing this form by hand, please use black ink and BLOCK CAPITAL LETTERS.
You are completing this form because there are allegations that the child(ren) listed in this form may have suered or
be at risk of suering domestic abuse, violence/abuse.
“Domestic violence/abuse” means any incident of threatening behaviour, violence or abuse (psychological, physical,
sexual, nancial or emotional) between adults who are or have been intimate partners or family members regardless
of gender or sexuality.
The Children Act 1989 denes the following terms as:
“Harm” means ill treatment or damage to health and development, including, for example, damage suered from
seeing or hearing the ill treatment of another.
“Development” means physical, intellec tual, emotional, social or behavioural development.
“Health” means physical or mental health.
“Ill-treatment” includes sexual abuse and forms of ill-treatment which are not physical.
Section 1 - About you (the person completing this form)
Your full name
Gender Male Female
Are you the Applicant Respondent
Contact telephone number
Have you completed the form C8
(Condential contact details)?
See Section 1 of the guidance notes.
Yes No Not applicable
Name of child(ren) Date of birth Gender Relationship to you
D D / M M / Y Y Y Y Male Female
D D / M M / Y Y Y Y Male Female
D D / M M / Y Y Y Y Male Female
C1A Allegations of harm and domestic violence (Supplemental information form) (01.16) © Crown copy right 2016
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