1. Has (.....) had problems in the past year with drugs (prescription or other), alcohol or mental health leading to problems in leading a normal life? (If yes, please specify which and give relevant details if known.) Drugs ☐ Alcohol ☐ Mental Health ☐ ☐ ☐ ☐
  2. Has (.....) ever threatened or attempted suicide? ☐ ☐ ☐
  3. Has (.....) ever broken bail/an injunction and/or formal agreement for when they can see you and/or the children? (You may wish to consider this in relation to an ex-partner of the perpetrator if relevant.) Bail conditions ☐ Non Molestation/Occupation Order ☐ Child Contact arrangements ☐ Forced Marriage Protection Order ☐ Other ☐ ☐ ☐ ☐
  4. Do you know if (.....) has ever been in trouble with the police or has a criminal history? (If yes, please specify.) DV ☐ Sexual violence ☐ Other violence ☐ Other ☐ ☐ ☐ ☐

Total ‘yes’ responses

For consideration by professional: Is there any other relevant information (from victim or professional) which may increase risk levels? Consider victim’s situation in relation to disability, substance misuse, mental health issues, cultural/language barriers, ‘honour’- based systems and minimisation. Are they willing to engage with your service? Describe: Consider abuser’s occupation/interests - could this give them unique access to weapons? Describe: What are the victim’s greatest priorities to address their safety?