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Domestic Violence Risk Assessment
01
Initial Contact and Intake
02
Program Contract
03
Waiver of Confidentiality
04
Promise to Maintain Confidentiality
05
Program Policy
06
BTP Fees Payment Assessment
07
Drug and Alcohol Assessment
08
Risk Assessment
Domestic Violence Risk Assessment
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Name
Today's Date
What is your age?
What is your gender?
Please select
Male
Female
Others
If Others, Please list it here
Number of marriages
Number of relationships resulting in children
Weekly Alcohol consumption
Are you an alcoholic?
Yes
No
In Recovery?
Yes
No
Weekly illicit (Illegal or non-prescribed drug) usage, including Marijuana
Drug of choice
List drugs used in the last 6 months
Family History of Illicit drug use
Criminal Arrests (since 18)
Convictions
Felonies
Misdemeanors
Family History of Criminal arrests and convictions
Employment
Currently employed
F/T
P/T
Temp
Unemp
Last 6 months
F/T
P/T
Temp
Unemp
Parental History of employment
Diagnosed Mental Health Issues i.e. Depression, Anxiety, PTSD, OCD, Bi-Polar, TBI, Borderline, Narcissistic PD, eating disorders, drug usage disorders, Schizophrenia, etc.
a. Have you been prescribed medications?
Yes
No
b.List them
c.Do you take as prescribed?
Yes
No
d.How long have you been talking medications?
Family History of Mental Illness
Highest level of formal education completed
Parents education level
Living situation: i.e. rent, own, live with friend or family member, rent a room, roommates, couch surf, homeless, etc.
Length of time in current living situation
Current Stress and/or Frustration level
Please select
1
2
3
4
5
6
7
8
9
10
Current Health Level
Please select
1
2
3
4
5
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7
8
9
10
Current level of Daily Restorative Sleep
Please select
1
2
3
4
5
6
7
8
9
10
Current level of average weekly exercise in minutes
Please select
1
2
3
4
5
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9
10
Diet and Nutritional Intake
Please select
1
2
3
4
5
6
7
8
9
10
Rate your overall health
Please select
1
2
3
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9
10
Family Origin
How were you disciplined as a child?
Were your parents continually married to one another while growing up?
Peers
a. Do your peers use force and use of violence as acceptable problem solving behavior?
b. Do your peers consume excessive amounts of alcohol regularly?
c. Do your peers consume illicit drugs?
Submit
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