Domestic Violence Risk Assessment

Name(Required)

First Last

Date(Required)

Email(Required)

Phone(Required)

Have they ever used a weapon against you/threatened you with a weapon?(Required)

Have they threatened to kill you or your children?(Required)

Do you think they might try to kill you?(Required)

Does they have a gun or can get one easily?(Required)

Have they ever tried to choke you?(Required)

Are they constantly jealous or do they control most of your daily activities?(Required)

Do they follow or spy on you or leave threatening messages?(Required)

Have you left them or separated after living together or being married?(Required)

Are they unemployed?(Required)

Have they tried to kill themself?(Required)

Do you have children together?(Required)

Do you have a child that they know is not theirs?(Required)

Have they been physical toward the children in a way that concerns you?(Required)

Do they have an alcohol or substance abuse problem?(Required)

Have they interfered with a 911 call?(Required)

Is there anything else that worries you about your safety? Explain Below: