Danger assessment

Has the physical violence increased in severity or frequency over the past year?

Yes No

Does your partner own a gun?

Yes No

Have you left your partner after living together during the past year?

Yes No

Is your partner unemployed?

Yes No

Has your partner ever used a weapon against you or threatened you with a lethal weapon?

Yes No

Does your partner threaten to kill you?

Yes No

Has your partner avoided being arrested for domestic violence?

Yes No

Do you have a child that is not not his/hers

Yes No

Has your partner ever forced you to have sex when you did not wish to do so?

Yes No

Does your partner ever try to choke/strangle you or cut off your breathing?

Yes No

Does your partner use illegal drugs? (z.B. cocaine, heroine, meth, amphetamines)

Yes No

Is your partner an alcoholic or problem drinker?

Yes No

Does your partner control most or all of your daily activities? (e.g. he/she tells you who you can be friends with, when you can see your family or how you use money)

Yes No

Is your partner violently and constantly jealous of you? (e.g. "If I can't have you, no one can")

Yes No

Have you ever been beaten while you were pregnant?

Yes No

Has your partner ever threatened or tried to commit suicide?

Yes No

Does your partner threaten to harm your children?

Yes No

Do you believe your partner is capable of killing you?

Yes No

Does your partner follow or spy on you, leave you threatening messages, destroys your property, or call you when you don't want him/her to?

Yes No

Have you ever threatened or tried to commit suicide?

Yes No

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