Is the abuse getting worse? ☐ ☐ ☐

Does (.....) try to control everything you do and/or are they excessively jealous? (In terms of relationships, who you see, being ‘policed at home’, telling you what to wear for example. Consider ‘honour’-based violence and specify behaviour.) ☐ ☐ ☐

Tick box if factor is present. Please use the comment box at the end of the form to expand on any answer. Yes (tick) No Don’t Know State source of info if not the victim

Has (.....) ever threatened to kill you or someone else and you believed them? (If yes, tick who.) You ☐ Children ☐ Other (please specify) ☐ ☐ ☐ ☐

Has (.....) ever attempted to strangle/choke/suffocate/drown you? ☐ ☐ ☐

Does (.....) do or say things of a sexual nature that make you feel bad or that physically hurt you or someone else? (If someone else, specify who.) ☐ ☐ ☐

Is there any other person who has threatened you or who you are afraid of? (If yes, please specify whom and why. Consider extended family if HBV.) ☐ ☐ ☐

Do you know if (.....) has hurt anyone else? (Please specify whom including the children, siblings or elderly relatives. Consider HBV.) Children ☐ Another family member ☐ Someone from a previous relationship ☐ Other (please specify) ☐ ☐ ☐ ☐

Has (.....) ever mistreated an animal or the family pet? ☐ ☐ ☐

Are there any financial issues? For example, are you dependent on (.....) for money/have they recently lost their job/other financial issues? ☐ ☐ ☐

Has (.....) ever used weapons or objects to hurt you? ☐ ☐ ☐