A
B
C
D
E
Sl.
No.
Violence
by the Respondent
Consequences
of violence mentioned in column A suffered by the aggrieved
person
Apprehensions
of the aggrieved person regarding violence mentioned in column A
Measures
required for safety
Orders
sought from the Court
1.
Physical
violence by the Respondent
Complainant's
perception that she and her children are at risk of repetition of
physical
violence
(a)
Repetition
(b)
Escalation
(c)
Fear of injury
(d)
Any other, specify
2.
Any
sexual act abusing, humiliating or degrading, otherwise violative
of your dignity
(a)
Depression
(b)
At risk of repetition of such an act
(c)
Facing attempts to commit such acts
(a)
Repetition
(b)
Escalation
(c)
Any other, specify
3.
Attempts
at strangulation
(a)
Physical injury
(b)
Mental ill health
(c)
Any other, specify
(a)
Repetition
(b)
Any other, specify
4.
Beatings
to the children
(a)
Injury to the children
(b)
Adverse mental effect of the same on the children
(c)
Any other, specify
(a)
Risk of repetition
(b)
Adverse effect of violent behaviour/environment on the child
5.
Threats
to commit suicide by the Respondent
(a)
Violent environment in the house
(b)
Threat to safety
(c)
Any other, specify
(a)
Actually trying to commit the same
(b)
Repetition
(c)
Any other, specify
6.
Attempts
to commit suicide by the Respondent
(a)
Violent environment in the house
(b)
Insecurity, anxiety, depression, mental trauma
(c)
Any other, specify
(a)
Repetition, escalation, aggravation of the same
(b)
Mental trauma, pain
(c)
Any other, specify
7.
Psychological
and Emotional abuse of the Complainant like insults, ridicule,
name calling, insults for not having a male child, false
accusations of unchastity, etc.
(a)
Depression
(b)
Mental trauma, pain
(c)
Unsuitable atmosphere for the child/children
(d)
Any other, specify
(a)
Repetition, escalation, aggravation of the same
(b)
Mental trauma, pain
(c)
Any other, specify
8.
Making
verbal threats to cause harm to the aggrieved person/her
children/parents/relatives
(a)
Living in constant fear
(b)
Mental trauma, pain
(c)
Any other, specify
(a)
Respondent may carry out the mentioned threats
(b)
Mental trauma, pain
(c)
Any other, specify
9.
Forcing
not to attend school/college/any other educational institution
(a)
Depression
(b)
Mental trauma, pain
(c)
Any other, specify
(a)
Repetition
(b)
Mental trauma, pain
(c)
Any other, specify
10.
Forcing
to get married when do not want to/forcing not to marry a person
of choice/forcing to marry a particular person of Respondent/s'
choice
(a)
Depression
(b)
Mental trauma, pain
(c)
Fear of being married forcibly
(d)
Any other
(a)
Repetition
(b)
Mental trauma, pain
(c)
Any other
11.
Threatening
to kidnap
(a)
Living in constant fear
(b)Threat
to the child/children's safety
(c)
Any other, specify
(a)
Children might be kidnapped
(b)
Any other, specify
12.
Actually
causing harm to the aggrieved
person/children/relatives
(a)
Living in constant fear of further harm
(b)
Any other, specify
(a)
Repetition
(b)
Escalation
(c)
Fear of injury
(d)
Any other, specify
13.
Substance
abuse
(drugs/alcohol)
(a)
Living in constant fear of abusive and violent behaviour by the
Respondent due to substance abuse
(b)
Deprived of leading a normal life
(c)
Any other, specify
(a)
Physical violence after consuming the same
(b)
Abusive behaviour after consuming the same
(c)
Non-payment of maintenance / household expenses
(d)
Any other, specify
14.
History
of criminal behaviour
(a)
Constant fear of violence
(b)
Fear of revenge by the Respondent
(a)
Respondent has a tendency to violate law and is likely to flout
orders passed by the Court against him
(b)
Respondent might cause harm to the aggrieved person/children for
filing any further proceedings
(c)
Any other, specify
15.
Not
provided money towards maintenance, food, clothes, medicines,
etc.
(a)
Driven towards vagrancy and destitution
(b)
Any other, specify
(a)
Have to face great hardship to fulfill the needs and requirements
of her child/children and herself
(b)
Any other, specify
16.
Stopped,
disturbed from carrying on employment or not allowed to take up
the
same
(a)
Not able to fulfill the basic needs for yourself and your
children
(b)
Any other, specify
(a)
Have to face great hardship to fulfill the needs and requirements
of her child/children and herself
(b)
Any other, specify
17.
Forced
out of the house, stopped from accessing or using any part of the
house or prevented from leaving the same
(a)
Having no place to stay for yourself and your children
(b)
Being restricted to a particular area of the house
(a)
Safety of her child/children and herself
(b)
Have to face great hardship in providing shelter for her and her
children
(c)
Any other, specify
18.
Not
allowed use of clothes, articles or things of general household
use
(a)
Losing possession of the same
(b)
Not having resources to replace the same
(a)
The same may be disposed off by the Respondent
(b)
Any other
19.
Non-payment
of rent in case of a rented
accommodation
(a)
Being asked to leave the same by the owner on such non-payment
(b)
No alternate accommodation to go to
(c)
No income to afford a rented accommodation
(a)
Losing shelter
(b)
Facing great hardship
(c)
Any other, specify
20.
Sold,
pawned stridhan or any other valuables without informing or
without consent
(a)
Loss of valuables or property
(b)
Any other, specify
(a)
The same maybe disposed off by the Respondent
(b)
Any other, specify
21.
Dispossessed
of stridhan
(a)
Deprived of the property in her
possession
(b)
Any other, specify
(a)
The same may be disposed off by the Respondent
(b)
Fear of never receiving the same again
(c)
Any other, specify
22.
Breach
of civil/criminal Court order, specify order
Please
specify
Please
specify
…...............................
Signature
Aggrieved
Person
…...............................
Signature
Service
Provider/Protection Officer/Police Officer
FORM VI
[See rule 11(1)]
Form For Registration As Service Providers Under Section 10(1) Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)
1.
Name of the
applicant
2.
Address alongwith
phone number, e-mail address, if any
3.
Services being
rendered
❑Shelter
❑Psychiatric
counselling
❑Family
counselling
❑Vocational
Training Centre
❑Medical
Assistance
❑Awareness
Programme
❑Counselling
for a group of people who are victims of domestic violence and
family disputes
❑Any
other, specify
4.
Number of persons
employed for providing such services
5.
Whether
providing the required services in your institution requires
certain statutory minimum professional qualification? If yes,
please specify and give details
6.
Whether
list of names of the persons and the capacity in which they are
working and their professional qualification is attached?
❑Yes
❑No
7.
Period for which
the services are being rendered
❑3
years
❑4
years
❑5
years
❑6
years
❑More
than 6 years
8.
Whether
registered under any law/regulation
❑Yes
❑No
If yes, give the
registration Number
9.
Whether
requirements prescribed by any regulatory body or law fulfilled?
If yes, the name
and address of the regulatory body
Note.-In
case of a shelter home, details under columns 10 to 18 are to be
entered by registering authority after inspection of the shelter
home.
10.
Whether there is
adequate space in the shelter home
❑Yes
❑No
11.
Measured area of
the entire premise
12.
Number of rooms
13.
Area of the
rooms
14.
Details of
security arrangements available
15.
Whether
a record available for maintaining a functional telephone
connection for the use of inmates for the last 3 years
16.
Distance of the
nearest dispensary/clinic/medical facility
17.
Whether
any arrangement for regular visits by a medical professional has
been made?
❑Yes
❑No
If yes, name of
the
Medical
Professional
Address
...............................................................................................
...............................................................................................
...............................................................................................
Contract
number
...............................................................................................
...............................................................................................
Qualification
...............................................................................................
...............................................................................................
Specialisation
...............................................................................................
...............................................................................................
18.
Any
other facilities available, specify
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Note.-In
case of a counselling centre, details under columns 19 to 25 are
to be entered after inspection by registering authority.
19.
Number
of Counsellors in the centre
................................................................................................................................................
................................................................................................................................................
20.
Minimum
qualification of the Counsellors, specify
❑Under
graduate
❑Graduate
❑Post
graduate
❑Diploma
holder
❑Professional
degree
❑Any
other, specify
21.
Experience
of the Counsellors
❑Less
than a year
❑1
year
❑2
years
❑3
years
❑More
than 3 years
22.
Professional
qualification/experience of Counsellors
❑Professional
degree
❑Experience
in family counselling as a
..............................................(designation) in
the ..............................................(Name of the
organisation)
❑Experience
in psychiatric counselling as
..........................................(designation) in the
..............................................(Name of the
organisation)
❑Any
other relevant experience, please specify
.......................................................................................................................................
......................................................................................................................................
.......................................................................................................................................
23.
Whether
a list of names of Counsellors alongwith their qualifications
has been annexed
❑Yes
❑No
24.(a)
Type
of counselling provided
❑Supportive
one-to-one counselling
❑Cognitive
behaviourable therapy (CBT) (Mental process that people use to
remember, reason, understand, solve problems and judge things)
❑Providing
counselling to a group of people suffering
❑Family
counselling
(b)
Facilities
provided
❑Offering
personal professional and confidential counselling sessions
❑A
safe environment to discuss problems and express emotions
❑Information
on counselling services, support groups and mental health care
resources
❑One-to-one
counselling and group work
❑Therapies,
ongoing counselling and health related support
❑Any
other, please specify
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
(c)
.
Any
other service
(1)
Services being provided
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
(2)
Personnel appointed
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
(3)
Statutory minimum qualifications required for providing such
service
.......................................................................................................................................
......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
(4)
Whether a list of names of personnel engaged for providing
service alongwith their professional qualification is annexed
❑Yes
❑No
(5)
Any other details which the service provider desirous of
registration may provide
...........................If
necessary continue on a separate sheet.
Place ...................................
Date .....................................
.....................................
Signature of authorised official
Designation
FORM VII
[See rule 11(1)]
Notice For Appearance Under Section 13(1) Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)
In The Court Of ......................................................................
P/S :............................................
In the matter Of:
Ms
...............................................& Others
.....................COMPLAINANT
Versus
Mr
...............................................& Others
.........................RESPONDENT
To,
Mr .....................................................
S/o ...................................................
R/o ...................................................
............................................................
............................................................
Whereas the petitioner has filed an application(s) under section ...................of the Protection of Women from Domestic Violence Act, 2005 (43 of 2005).
You are hereby directed to appear before this Court on the ............................day of ............................20...........at...........O'clock in the............................noon personally or through a duly authorised counsel of this Court to show cause why the relief(s) claimed by the Applicant against you should not be granted, failing which the Court shall proceed ex parte against you.
Given under my hand and the seal of the Court of ............................on the............................ day of ............................20...........
...........................
Signature
Seal of the Court