Domestic Violence Screening
Please answer the following questions to help us understand your situation and provide appropriate support. Your responses are confidential.
Full Name
First Name
Last Name
Are you currently experiencing any of the following? (Select all that apply)
*
Physical abuse: hit, slapped, kicked, pushed, bitten, grabbed roughly
Have you ever been choked or strangled? (If the client answered yes, please provide a safety plan for client.)
Sexual abuse: coerced into sex; forced or pressured you to perform sexual acts
Human trafficking assessment: Forced or pressured to provide labor, services, or sex in exchange for money, housing, transportation, drugs, or under manipulation?
Financial abuse: controlling your money, not letting you open a bank account, stealing food stamps, SSI, or any form of income?
Destroyed property or belongings to intimidate you?
Threatened your children or someone you love?
Other
Are you currently experiencing any of the following due to a current or former partner?
Safety concerns
Housing instability
Financial difficulties
Transportation problems
Legal/custody concerns
Problems at your workplace
Isolation
Child safety concerns
Other
Who is the person responsible for this behavior?
*
Current partner or spouse
Former partner or spouse
Family member
Other
Do you feel safe in your current living situation?
*
Yes
No
Not sure
Have you stayed in a shelter before?
Yes
No
If answered 'yes', which shelters have you stayed in?
Would you like to be contacted for support or resources?
*
Yes
No
If yes, please provide your preferred contact method.
Phone call
Text message
Email
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Is there anything else you would like us to know?
Submit
Should be Empty: