Dallas County Protective Order

You’re offline. This is a read only version of the page.

URGENT ATTENTION REQUIRED

THIS IS NOT A PROTECTIVE ORDER.

THIS IS NOT AN APPLICATION FOR A PROTECTIVE ORDER.

This is the Dallas County Criminal District Attorney’s Office Protective Order Questionnaire. It is used to gather information prior to you receiving a call from a victim advocate to assess your protective order case.

If you need a protective order right now — that is, your situation is such that you cannot wait for this office to process your paperwork and contact you — you are urged to hire an attorney or file an Application for a Protective Order on your own. There is no cost to file an Application for a Protective Order with the court. Resources like the Law Library and TexasLawHelp.org are commonly used.

If you are currently charged with a criminal offense, filling out this form may waive your Sixth Amendment right to remain silent. You should speak to your attorney before filling out this information. If you are represented by counsel, you should not communicate with The District Attorney’s Office.

I have read and understand the foregoing statements.

Waiver of Confidential Information

I, the undersigned Applicant, acknowledge and confirm that I waive all confidential information I provide to the Dallas County Criminal District Attorney’s Office, their attorneys and staff (referred to in this waiver as “DCCDA”), in the process of making an application for a protective order and in the pursuing of a protective order on my behalf.

I understand that “confidential information” includes both “privileged information” and “unprivileged information.” “Privileged information” refers to information protected by the attorney-client privilege. “Unprivileged information” means all information relating to or furnished by me that is acquired by the DCCDA during the course of or by reason of their representation of me in my application for a protective order.

I understand that the DCCDA may use and reveal my confidential information:

If it represents potentially exculpatory information under Brady v. Maryland, the Michael Morton Act, Texas Code of Criminal Procedure 39.14, or Texas Disciplinary Rule 3.09.

To the extent reasonably necessary to enforce a claim or establish a defense of the DCCDA.

When the DCCDA has reason to believe it is necessary to prevent the commission of a criminal or fraudulent act.

To the extent reasonably necessary to rectify the consequences of a criminal or fraudulent act in which the DCCDA was used during the protective order application process.

When the DCCDA believes it is necessary to do so in order to:

Carry out the representation effectively;

Defend the DCCDA against a claim of wrongful conduct.

Signature (enter your name) *

Date *

Eligibility for a Protective Order

I. Residence (Jurisdiction)

Do you or the respondent reside in Dallas County?

Yes

No

City of Residence *

County of Residence

Did an incidence of violence, sex assault or stalking occur in Dallas County?

Yes

No

City the incidence happened *

County

II. Case History

a. Have you ever filed for a Protective Order in this office?

Yes

No

Please provide details of your previous filing:

Status

b. Has anyone ever filed a Protective Order against you in this office?

Yes

No

Was the Protective Order granted to the Applicant?

Yes

No

c. Civil cases with the respondent

Pending Cases: (Check all that apply. Leave blank if none.)

Divorce

Custody

Child Support

Final Orders: (Check all that apply. Leave blank if none.)

Divorce

Custody

Child Support

d. Do you have any criminal cases pending against you?

Yes

No

Have you ever had criminal charges filed against you?

Yes

No

e. Have you ever been investigated by Child Welfare (CPS)?

Yes

No

Do you have any CPS cases pending?

Yes

No

f. Are you a registered sex offender?

Yes

No

I have read and understood the Protective Order information that was given to me when I applied for this order.

Yes

No

Applicant’s Initials

Names of Parties

Applicant Information (Your Details)

First Name *

Middle Name

Last Name *

Maiden Name

Respondent Information (Person the Order is Against)

First Name *

Middle Name

Last Name *

Maiden Name

Do you and Respondent CURRENTLY live together? *

Yes

No

Respondent's Address

Respondent's address is unknown

Street Address

Apt/Unit

City

State

Zip

Respondent Home Phone

Respondent Mobile Phone

Applicant's relationship to Respondent *

Please specify *

Applicant's Demographic Information

Sex *

Male

Female

Other

Pregnancy information (Optional but helpful)

Are you pregnant?

Yes

No

Unknown

Were you abused while pregnant?

Yes

No

Race *

Language *

Place of Birth *

Birthdate *

Age

Applicant's Household Information

Applicant's current physical address (where currently reside):

Street Address *

Zip Code *

Apt #

City *

State *

Do you want the address to be marked as confidential? *

Yes

No

A victim advocate will call you to discuss this questionnaire. It is VERY important that you provide at least one contact phone number. If we are unable to reach you, we will leave a voicemail or message or may send an email. Be sure the voicemail is setup and not full. If you and the For your safety, if you and Respondent are living together, please provide a phone number or email that is safe for us to contact you. For any assistance call (214) 653-3528.

Preferred Method of Contact *

Home Phone

Mobile Phone

Email

Does the respondent know where you live? *

Yes

No

Unknown

Do you have children? *

Yes

No

Applicant's mailing address (if different from physical address):

Street Address

Zip Code

Apt #

City

State

Friend/Relative (not living with you) you authorize us to leave a message with for you or to assist in locating you:

First Name *

Middle Name

Last Name *

Home Phone

Mobile Phone

Work Phone

Applicant's Employment/School-information

Employment Status

Are you employed? *

Yes

No

Work Address

Street Address

City

State

Zip

Phone

Does the respondent know where you work?

Yes

No

Unknown

May messages be left for you at work?

Yes

No

School/Educational Status

Are you currently attending school? *

Yes

No

School Address

Street Address

Phone

City

State

Zip

Does the respondent know where you attend school?

Yes

No

Unknown

About the Respondent

Respondent's Demographic Information

Respondent Sex *

Male

Female

Other

Race *

Language *
Specify language

Date of Birth

Age

Place of Birth

Is the respondent on Parole/Probation? *

Yes

No

Unknown

Reason for parole/probation

County

Does the respondent have any known weapons? *

Yes

No

Known Weapons

Physical Description

Height

Weight (lbs.)

Hair Color

Facial Hair?

Yes

No

Glasses?

Yes

No

Contacts?

Yes

No

Eye Color

Tattoos

Scars

Body Piercing(s)

Other of note

Vehicle-information

Vehicle Make

Model

Year

Color

License Plate #

Relationship Information

Have you ever received any treatment/services because of abuse in THIS relationship?

Yes

No

Please select the treatment/services you received.

Hospital

Yes

No

Doctor

Yes

No

Dentist

Yes

No

Counselor

Yes

No

Emergency Room

Yes

No

Other

Yes

No

Details About Family Violence / Sexual Assault / Stalking / Human Trafficking / Burglary

Identify the three (3) most recent incidents that cause you to believe you need a protective order. Describe how Respondent threatened to, tried to, or actually caused you or a member of your family or household physical harm, bodily injury, assault or sexual assault. Also, include incidents of harassment, stalking and trafficking. YOU MUST ADD AT LEAST ONE INCIDENT HERE.

Date City State Description Injured? Weapons? Photos? Witnesses? Police Called? Actions

(No incidents listed)

Incident Information

Date of Incident *

City *

State

Briefly describe what happened (3000 characters max) *

Were you physically injured?

Yes

No

Briefly describe your injuries (255 characters max)

Were weapons or objects used on you?

Yes

No

If yes, what kind?

Are there photos of your injuries?

Yes

No

If yes, who took them?

Taken by me

Taken by friend/family

Taken by police

Other

Any witnesses?

Yes

No

If yes, please provide the name, relationship and telephone number (100 characters max)

Were the police called?

Yes

No

Report Number

Respondent Arrested?

Yes

No

Is Respondent currently in jail? *

Yes

No

What jail?

Was an Emergency Protective Order (EPO) issued? *

Yes

No

Unknown

Court/Legal and Social Services

Have you ever been given a ticket, arrested, charged, convicted, or placed on probation for committing a violent act against anyone?

Yes

No

Brief explanation:

Have you ever been the subject (respondent) of a protective order?

Yes

No

Year

City

State

Briefly explain:

Have you ever been the protected party (Applicant) in a protective order?

Yes

No

Who did the order protect you from?Briefly explain:

Has Respondent ever hurt or harmed any of your children?

Yes

No

Details of abuse / Child(ren) name(s)

Has the Texas Department of Family and Protective Services (DFPS) been notified?

Yes

No

Date

Case Worker Name

Phone

Have the police ever been notified of child abuse?

Yes

No

Date

Officer Name

Phone

Have criminal charges ever been filed against this person for child abuse?

Yes

No

Date

County

Case #

Disclaimer and Signature

How did you find out about this office? *

Please specify:

I have read and understand the following (must select all):
This questionnaire begins the protective order case review process.

This is not an Application for a Protective Order.

This is not a Protective Order enforceable by law enforcement.

Information may be shared with the criminal division if a case is associated.

Applicant (type full name) *

Date *

This questionnaire was completed partially or entirely by a person other than the Applicant named above?

Yes

No

Name of person who helped complete this questionnaire:

Please check all responses below that apply:
I completed this questionnaire on behalf of a minor who is my child, ward or foster child.

I completed this questionnaire on behalf of a minor who is not my child, ward or foster child.

I am a family member of the adult Applicant.

I am a friend of the adult Applicant.

I assisted as an interpreter, translating the questionnaire into the Applicant’s preferred language.

I assisted the Applicant by explaining the questionnaire.

I am an employee/volunteer of a law enforcement agency.

I am an employee/volunteer of a social service agency.

Other (please specify):

Would you like a submission confirmation sent to your email?

Yes

No

Enter your email address:

Signature *

See Preview

Please wait… submitting your information.

📄 Form Preview

URGENT ATTENTION REQUIRED

Introduction to the Protective Order Process

⚠️ Important! Questionnaire Instructions

1. What is a Protective Order?

2. The Protective Order Process

How to Get Started

What Happens After Submission?

3. Will the Dallas County Criminal District Attorney's office (DCCDA) Assist with My Case?

Waiver of Confidential Information

I. Residence (Jurisdiction)

II. Case History

Names of Parties

Applicant Information (Your Details)

Respondent Information (Person the Order is Against)

Respondent's Address

Applicant's Demographic Information

Applicant's Household Information

Applicant's current physical address (where currently reside):

Applicant's mailing address (if different from physical address):

Friend/Relative (not living with you) you authorize us to leave a message with for you or to assist in locating you:

Applicant's Employment/School-information

Employment Status

Work Address

School/Educational Status

School Address

About the Respondent

Respondent's Demographic Information

Physical Description

Vehicle-information

Relationship Information

Details About Family Violence / Sexual Assault / Stalking / Human Trafficking / Burglary

Incident Information

Court/Legal and Social Services

Disclaimer and Signature

Would you like a submission confirmation sent to your email?