Relates to DVDRC #34, 37, 21
Your Age: _________________
Your partner’s age: ___________
Length of this relationship: ______
Married? YES NO
Common law? YES NO
Worker’s Name: __________________________
Relates to DVDRC #11
- Please answer the questions in the table below:
|a) Has your partner assaulted you, or been emotionally or sexually abusive with you?|
|b) Has he/she ever forced you to have sex when you did not wish to do so, with him or with others?|
|c) Has he/she ever choked/strangled you (put hands around your neck and squeezed you making it hard for you to breath)?|
|d) If you have been pregnant has your partner assaulted you during your pregnancy?|
|e) Have you ever received medical attention as a result of being assaulted?|
|f) Were there times when you should have sought medical attention but did not do so?|
If you answered yes to any of these questions please provide details.
2. To the best of your knowledge, has your partner assaulted or been abusive to any other person? (e.g. socially, to co-worker or strangers)? Please explain.
Relates to DVDRC #2
3 a) To the best of your knowledge has your partner assaulted or been emotionally or sexually abusive with any previous spouse(s)/intimate partner(s), family members, or children from another relationship? YES NO Please describe. How did you acquire this information? Relates to DVDRC #23
3b) Does your partner minimize or deny spousal assault history with you or others?
If yes, please describe.
Relates to DVDRC #1
3c) Does your partner have a history of violence outside the family? If yes, please describe.
3d) Were you forced into a marriage against your will?
Pets Relates to DVDRC #14
- Has your partner injured or killed a pet or domestic animal or threaten to do so?
- a) If yes please describe.
Children Relates to DVDRC #12, 22
5. How old are your children/stepchildren? Which children are from this relationship?
5 a) Were any of the child(ren) present during any of these incidents of abuse or violence (with any abuser)?: YES NO
If YES, which children were present? Please list them below.
|Describe Incident Witnessed:|
|Year Incident Occurred:|
|Child Physically Harmed:|
|Other harm to child: (i.e. Mental or Emotional)|
5 b) Please answer the questions in the table below:
|a) Has your partner ever removed children from your care?|
|b) Has your partner ever not returned children when required to do so?|
|c) Has your partner attempted or threatened to do so?|
|d) Is your partner using the children to control or influence you?|
|e) Do you fear for the safety of your children in the presence of your partner?|
If you answered yes to any of these questions, please provide details.
Relates to DVDRC #39
5 c) Did your partner threaten or harm the children? YES NO
5 d) Did you notice any changes in the child(ren)? YES NO If yes, please explain:
5 e) Have Family and Children’s Services (FCS) been involved with your family as a result of the children witnessing or being injured as a result of any of these incidents: YES NO
5 f) Please specify the exact nature of the FCS involvement in this case. (Check all that apply): FCS currently involved.
FCS not currently involved.
Relates to DVDRC #20
6 a) Is your partner experiencing an unusual degree of stress (family, financial, unemployment, immigration, racism, homophobia, disability, work-related medical, etc)?
6 b) How is your partner coping?
Relates to DVDRC #17
6 c) Was your partner abused or witnessed DV as a child? YES NO Describe:
Relates to DVDRC #32
6 d) Was your partner exposed to or witnessed suicidal behaviour in their family of origin? YES NO
Isolation 7 a) Does your partner have friends, family, or outside agencies for support? Please list these people.
7 b) Do you think your partner’s support system, if any, encourages or hinders your partner’s abusive behaviour?
Drugs and Alcohol Relates to DVDRC #25
8 a) Does your partner use drugs or alcohol? YES NO 8 b) How much and how often does your partner drink?
8 c) Is your partner drunk every day or almost every day?
8 d) What type of drugs are used and how frequently are they used?
8 e) Is you partner addicted to any drugs or alcohol, and if so, which substances?
8 f) Do you use drugs or alcohol? YES NO
Mental Health Relates to DVDRC #26, 27, 28
9 a) Is your partner under care for any mental health issues, or has your partner been under such care in the past? YES NO
9 b) If so, for what? Does your partner suffer from any delusions, paranoia or depression? Please Explain:
10 a) Is your partner on any prescription medications? YES NO
10 b) If yes, please describe all prescription medications. Is your partner taking such medication as prescribed?
10 c) Has your partner ever participated in any treatment programs for alcohol/substance abuse or mental health issues? YES NO
10 d) Has your partner ever refused to participate in such programs? YES NO
10 e) Please provide any details below:
10 f) Are you under any care for any mental health issues or have you been in the past? YES NO
- g) If so, please explain:
10 h) Are you on any prescription medications? YES NO
10 i) If yes, please describe all prescription medications. Are you taking them as prescribed?
10 j) Have you ever participated in any treatment programs for alcohol/substance abuse of mental health issues? YES NO
10 k) If yes, please describe:
Counselling 11 a) Has your partner ever participated or received counselling in a program designed to deal with domestic violence? YES NO
11 b) If yes, please describe.
11 c) What was your partner’s attitude about taking the program?
11 d) Did your partner benefit from the program?
11 f) Have you ever participated or received counselling designed to deal with DV? YES NO Please describe:
Court Orders Relates to DVDRC #31
12 a) Has your partner ever failed to obey any past family or criminal court order (e.g. breach of restraining order, breach of bail condition, breach of probation, breach of parole)?
12 b) If yes, please explain.
Property Relates to DVDRC #13
13a) Has your partner destroyed or damaged or threatened to damage any of your belongings or contents of your home? YES NO
13 b) Has your partner destroyed or damaged property owned by your children, other family members, or friends? YES NO
13 c) If yes, to any of the above please provide details below.
Prior Police Response Relates to DVDRC #2
14 a) Have the police been called to respond to any violent situations involving you and your partner prior to this incident? YES NO
14 b) If yes, which incident was reported and when?
14 c) What was the outcome? Please check all that apply.
|q||Incident reported||q||Abuser was not convicted||q||Warrant issued|
|q||Abuser was arrested & charged||q||Incident not reported||q||Protective/restraining order issued|
|q||Abuser was charged||q||Client was charged||q||Unknown|
|q||Abuser was convicted||q||Client was arrested||q||Other:|
14 d) Do you have any documentation relating to this/these incidents (i.e. restraining order etc)? YES NO
14 f) Please provide as much details as possible. (Please use additional sheets as needed).
14 g) What was your partner’s reaction?
14 h) If you were unable to report this/these incidents to the police, would you like to report it to them now? YES NO
14 i) Were you able to tell anyone else about this/these incident(s)? YES NO
14 j) If yes, who were you able to tell about this/these incident(s)? Circle all that apply. Lawyer Faith Leader Friend Relative Counsellor Other 14 k) Were any other social services involved?
Firearms and Weapons Relates to DVDRC #4, 5
15 a) In the past, has your partner owned or had access to any firearms or other weapons? YES NO
15 b) If so, please describe the firearms/ weapons and indicate whether they belonged to your partner or someone else.
15 c) Does your partner currently own or have access to any firearms or other weapons? YES NO
15 d) If so, please describe these firearms/ weapons, where they are presently located, and whether they are properly stored.
15 e) Has your partner ever possessed a firearms license or FAC (Firearms Acquisition Certificate)? YES NO
15 f) Does your partner currently possess one? YES NO
15 g) Where does your partner keep his/her firearms documentation? 15 h) Is your partner currently prohibited from possessing firearms? YES NO
15 i) Has your partner ever been prohibited from possessing firearms? YES NO
15 j) If yes, when and where did the prohibition order get made? When did it start and if over, when did it end? Why was the prohibition order made?
15 k) Please answer the questions in the table below.
|a) Is your partner familiar with the use of firearms or other weapons?|
|b) Has your partner received any previous training (e.g. military, law enforcement?)|
|c) Does your partner belong to any shooting clubs or ranges?|
|d) Has your partner expressed an obsession or fascination with firearms or other weapons?|
|e) Does your partner subscribe to or read any firearms or paramilitary publications?|
If yes, to any of the above questions please provide relevant details below.
15 l) Has your partner ever used, or threatened to use firearms or other weapons on other occasions in the past? Explain.
Separation Relates to DVDRC #24
16 a) Have you ever separated or discussed separation with your partner? YES NO
16 b) If so, when?
16 c) How is your partner reacting (e.g. aggressive, threatening, jealous, depressed, etc.)?
16 d) Do you have any concerns for your safety?
Controlling Behaviours Relates to DVDRC #8, 9, 10, 19, 35, 36
17 a) How does your partner behave with you?
|a) Is your partner obsesses, jealous, or controlling with you?|
|b) Has your partner ever confined you, or prevented you from using the telephone, leaving the house, going to work, or contacting family or friends?|
|c) Does he/she control most or all of your daily activities?|
|d) Does he/she tell you how much money you can use or when you can take the car?|
|e) Does your partner withhold medical care or support?|
|f) Are you dependent on your partner for attendant care or to your daily needs relating to a disability?|
|g) Are you sponsored by your partner or your partner’s family?|
|h) Does he/she control your immigration documents?|
|i) Has your partner threatened to “out” you to friends, co-workers, or family?|
|j) Has your partner every forced you to use drugs?|
|k) Has your partner ever isolated you, intimidated you, or belittled you?|
17 b) If you answered yes to any of these questions, please provide details.
Relates to DVDRC #2
17 c) To the best of your knowledge has your partner displayed any of the behaviours listed in Question #17a in previous relationships? How are you aware of this information?
Threats to Harm Relates to DVDRC #3
18 a) Has your partner ever threatened to kill you or harm you? YES NO
18 b) When these threats were made, in these threats, have there been specific details of a plan or method (e.g. a specific weapon or dangerous act)?
18 c) Has your partner ever attempted to act on such threats?
Relates to DVDRC #39
18 d) Has your partner ever threatened to kill or harm other family members, children, friends, or helping professionals? YES NO
18 e) When these threats were made, in these threats have there been any specific details of a plan or method (e.g. specific weapon or dangerous act)?
18 f) Has your partner ever attempted to act on such threats?
Relates to DVDRC #6
18 g) Has your partner ever threatened or tried to commit suicide? YES NO
18 h) If so, when? In these threats have there been specific details of a plan or method (e.g. a specific weapon or dangerous act)?
19 a) Has your partner engaged in any of the following behaviours with you in the past?
|a) Harassing phone calls or other communications to you, your friends, or family?|
|b) Watching, photographing or videotaping you, your friends or family?|
|c) Letter writing?|
|d) Leaving notes?|
|e) Frequenting or appearing at your workplace?|
|g) Cyber stalking – flooding you with emails, tracking/following/commenting on social media e.g. Facebook, twitter, etc?|
|h) Contacting you through third parties?|
19 b) If yes, when did they occur and under what circumstances? Did any of these behaviours result in face-to-face contact?
19 c) Does he know your passwords: online passwords, email, banking? YES NO
19 d) Do you have a “family plan” on your cell phone and/or is your partner named on your account? (i.e. has access to your records, bills, etc.) YES NO
19 e) Does he know someone who works for the phone/cable company? YES NO
19 f) Is your car “low-jacked” (have a GPS devise installed) and does your partner have access to this information? YES NO
19 g) To the best of your knowledge, has your partner engaged in any of the behaviours in Question # 19a) with any other persons? When did this occur and under what circumstances? If so, how did you acquire this information?
Escalation Relates to DVDRC #18
20 a) Has there been an increase in severity and frequency of abuse, stalking and/or controlling behaviours and/or threats to kill by your partner during the past year?
21 a) Do you have a new partner? YES NO
If yes, please describe:
21 b) Does your previous partner know about your current relationship? If yes, what was his reaction to that?
21 c) Do any of the above questions/situations apply to your new partner? YES NO
If Yes, please describe:
FEARS AND CONCERNS Relates to DVDRC #38
21 a) Please answer the questions in the table below:
|a) Do you believe your partner is capable of severely injuring or killing you (or your family or anyone else)?|
|b) Do you believe your partner is capable of committing suicide?|
|c) Do you have any fears for your safety or the safety of others?|
21 b) If you answered yes to any of the above questions, what are your fears, and why?
____________________________________ ___________________________________ Worker: Date: (completing the assessment)
Manager: (electronic signature) Date: