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Risk Assessment Questionnaire

How to Complete This Questionnaire

Answer each question about the person you are seeking help about. We use the word “partner” throughout, but this applies to any current or former spouse, boyfriend, girlfriend, or dating partner.

For each question, mark Yes, No, N/A (does not apply), or Unsure. “Unsure” is a perfectly valid answer—we can discuss those items together. Some questions ask about things that may have happened at any time during the relationship. Think about the full history, not just recent events.

You may skip any question you are not comfortable answering. We can discuss those later.

Please remember: you are not required to complete the section. This is a risk assessment intended to identify any significant areas of concern that we will need to keep in mind to help you stay safe; for that reason, some of the questions may be triggering. If you have any concerns, please speak with your advocate.

This doesn't have to be your real or full name, just one that we'll recognize when speaking further

Patterns

Has the physical violence gotten worse or happened more often in the past year?
This includes hitting harder, more frequent attacks, or injuries that are getting more serious over time.
Has your partner ever choked you, strangled you, or put their hands around your neck in a way that affected your breathing?
This includes any time you felt pressure on your throat, had trouble breathing, saw spots, felt dizzy, or lost consciousness. Even if it happened only once.
Has your partner ever forced you to have sex or perform sexual acts when you did not want to?
This includes physical force, threats, or situations where you felt you could not safely say no.
Were you ever physically hurt by your partner while you were pregnant?
If you have never been pregnant during this relationship, mark ‘Does Not Apply.’

Threats and Weapons

Has your partner ever directly threatened to kill you?
This includes saying “I’ll kill you,” “You won’t survive this,” or implying it while showing a weapon. It also includes indirect statements like “I’ll put you in the ground.”
Has your partner ever used a weapon against you or threatened you with one?
This includes guns, knives, bats, tools, vehicles, or any object used as a weapon—pointing, swinging, throwing, or striking.
Does your partner own a gun, or could they easily get access to one?
Includes guns kept at home, in a vehicle, at a relative’s house, or the ability to quickly buy or borrow one.
Has your partner ever threatened or attempted suicide, or said things like “I can’t live without you” or “If you leave, I’ll kill myself”?
Includes direct attempts, threats, or linking their survival to your relationship.

Control and Stalking

Does your partner control most of your daily activities?
Examples: telling you who you can see, when you can leave, how you spend money, checking your phone, requiring you to account for your time, or making major decisions without you.
Is your partner extremely jealous or possessive?
Examples: accusing you of cheating without reason, saying “if I can’t have you, no one can,” becoming angry when you talk to others, or treating you as their property.
Has your partner followed you, watched you, shown up uninvited, left threatening messages, or tracked your location?
Includes following in person, GPS tracking, showing up at work, monitoring through social media, or having others watch you on their behalf.
Has your partner used technology to monitor, control, or harass you?
Includes reading your texts/email without permission, installing tracking apps or spyware, controlling smart home devices, sharing private info online, or restricting your access to devices.

Relationship Situation

Have you recently left your partner, or are you planning or preparing to leave?
Includes having moved out, filed for divorce, told them it’s over, started a safety plan, or situations where they suspect you may be planning to leave.
Do you have a child living in your home who is not your partner’s biological child?
This means a child from a previous relationship who lives with you and your current partner.
Is your partner currently unemployed or experiencing serious financial problems?
Includes recent job loss, inability to find work, major debt, business failure, or financial stress that is affecting their behavior.
Does your partner use drugs (not including cannabis) or drink heavily?
Includes regular heavy drinking, binge drinking, methamphetamine, cocaine, opioids, or other drug use—especially if it makes them more aggressive or unpredictable.

Safety and Environment

Do any of the following describe where you live? (check all that apply)
These affect how quickly help can reach you in an emergency.
Is anything about your situation making it harder to seek help or leave safely? (check all that apply)
These do not make your partner more dangerous, but they affect your ability to get to safety. Your answers help us connect you with the right resources.
Are you or your household currently affected by a natural disaster, extreme weather, or major crisis (such as a hurricane, flood, wildfire, or pandemic)?
Events like these can disrupt services, trap you with your partner, and reduce your ability to get help. Research shows domestic violence often increases during and after disasters.
Is there an upcoming event that might make your situation more dangerous?
Examples: a court date, custody hearing, protective order being served, your partner finding out you’re leaving, a release from jail, or an anniversary of a significant event.

Additional History

Has your partner ever violated a restraining order, protective order, or other court order meant to protect you or someone else?
This includes showing up when ordered to stay away, contacting you when prohibited, or ignoring conditions of release.
Has the way your partner refers to you (or to other people that share common characteristics with you) negatively changed recently?
For example, using slurs, demeaning or dehumanizing language, etc

Your Own Assessment

Do you believe your partner is capable of seriously hurting or killing you?
Research consistently shows that a person’s own sense of danger is one of the strongest predictors of what actually happens.
Antimanual

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