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Risk Assessment Tool

This is a standalone risk assessment tool - any data entered into this form will NOT be saved. If you are going to report a crime, you will be asked to fill a risk assessment tool in, where the data will be saved alongside any other info you provide.

PLEASE NOTE: You do not have to fill in every box.

Domestic Violence form

1. Has the victim recently separated from, about to separate, or told partner that they want to separate?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

2. Does the partner/ex partner have a criminal record?

Yes No Don't Know

If Yes, please specify details including whether they have a history of violence against women or others, and where information was obtained from:

3. Has the current incident, or previous incident, resulted in injuries?

Yes No Don't Know

If Yes, please give more details of the injuries and also state what and whether this is the 1st injury, worst injury etc.

If 'Yes' does this cause significant concern?

4. Has the incident, or a previous incident, involved the use of weapons?

Yes No Don't Know

If Yes, please specify details including whether the perpetrator has access to weapons via their employment/leisure activities etc, and where information was obtained from:

If 'Yes' does this cause significant concern?

5. Has the perpetrator ever hurt or killed or threatened to hurt or kill anybody?

Yes No Don't Know

If 'yes', please tick all that apply.

Themselves
Service User
Children
Previous Intimate Partner
Others - Please Specify

If ‘Yes’ please provide more details in relation to who, and the level of threat posed i.e. does the victim/ person reporting, worker believe that the perpetrator could kill any of the above?

If 'Yes' does this cause concern that they could be a significant threat?

Does the victim believe that the perpetrator could kill them?

Yes No Don't Know

6. Has the perpetrator expressed/behaved in a jealous way or displayed controlling behaviour, or obsessive tendencies such as who the victim sees, are they being ‘policed at home/work/when away from perpetrator’ or told what to wear/stalked or harassed etc? (behaviour includes stalking, harassment, abusive or constant or unwanted phone calls or texts, checking their phone, whereabouts, sending letters, cards, presents, etc)

Yes No Don't Know

If yes please provide further details including what behaviour is happening, the context, and whether this is being done deliberately to intimidate and/or frighten the service user/victim.

If 'Yes' does this cause significant concern?

7. Is there any other person connected to the perpetrator who has threatened the service user/victim or made them afraid?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

8. Does the perpetrator have any of the following? Alcohol misuse issues, Drug or Pescription Drug misuse issues, Mental Health Issues or On Probation Perpetrator Programme?

Yes No Don't Know

If 'Yes', please tick all that apply

Alcohol misuse issues
Drug or Pescription Drug misuse issues
Mental Health Issues
On Probation Perpetrator Programme

If Yes, please specify details, and where information was obtained from:

9. Does the service user/victim have any of the following? Alcohol misuse issues, Drug or Pescription Drug misuse issues, Mental Health Issues or On Probation Perpetrator Programme?

Yes No Don't Know

If 'Yes', please tick all that apply

Alcohol misuse issues
Drug or Pescription Drug misuse issues
Mental Health Issues
On Probation Perpetrator Programme

If Yes, please specify details, and where information was obtained from:

10. Does the service user/victim have any financial problems, or are they financially dependent on the perpetrator?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

11. Does the perpetrator have any financial problems?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

12. Is the service user/victim pregnant, or do they have a baby under the age of 18 months?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

13. Is the victim afraid that the perpetrator will harm/or does he harm the children?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

14. Is there any conflict over children, e.g. child contact, residency/threats of abduction etc?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

15. Does the perpetrator live with children who are not biologically theirs?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

16. Is the victim afraid that the perpetrator will harm/or does he harm pets?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

17. Has the perpetrator ever attempted to strangle, choke, suffocate, drown or otherwise restrict the breathing of current partner/previous partner/and/or a child?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

18. Has the perpetrator said or done things of a sexual nature that have made the service user/victim feel bad/or used sexual violence against the service user/victim, or someone else?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

19. Has the service user/victim indicated in any way that they have previously fought back, or are likely to fight back, or retaliated in any way?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

20. Does the service user use social networking/instant messaging sites?

Yes No Don't Know

If Yes, please specify details:

21. Does the service user/victim feel isolated from family/friends or any other kind of support or help?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

22. Does the victim feel particularly isolated because of any personal, diversity or cultural issues?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

23. Has the service user/victim experienced a forced or coerced marriage, or do they feel under threat of forced or coerced marriage?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

24. Is there any actual or threatened abuse linked to the honour based code of the family and/or community?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

25. Has the service user/victim expressed suicidal thoughts, or have they ever made suicide attempts?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

26. Has a perpetrator expressed suicidal thoughts, or have they ever made suicide attempts?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

27. Are there any on-going court proceedings (divorce, children) or orders (non molestation, injunctions, restraining orders, court undertakings etc) in place/being applied for, or any bail/and or licence conditions in place?

Yes No Don't Know

If yes please state details of ongoing proceedings? How is the perpetrator responding to these proceedings, and has the perpetrator been non compliant with these orders/legal processes, or have they been non compliant previously?

28. Has the perpretrator destroyed property, or threatened to destroy property belonging to the victim, their children, family or friends?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

29. Did the relationship between the service user/victim and the perpetrator commence when the victim was in their teens, and is the perpetrator more than 5 years older than the victim?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

30. Has there been a recent downturn in the abuser's life (lost job, home, left the home, death of family member etc)?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

31. Has the perpetrator got a history of lighting fires/arson, or threatened to use fire to abuse the victim/children/family/friends/others?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

32. Is the service user/victim frightened, or afraid of further injury or violence?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from (Please give the service user’s/victim’s perception of the situation indicating what the victim thinks the perpetrator/and or others connected to the perpetrator will or won’t do)

33. What is the pattern of the abuse – is the abuse becoming more frequent, severe etc?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

34. Does the victim appear not to understand the seriousness of their situation, and/or the level of risk posed by perpetrator?

Yes No Don't Know

If Yes, please specify details, and where information was obtained from:

35. Police Callouts in last 12 months?

None Less than 3 3 or more Don't Know

If '3 or more' is selected Please Specify Details

Referrer's Perception of the situation
To conclude the risk assessment, please write a short background case summary below. Please write about the case in your own words, give your own perception and judgements, and give reasons as to why you are submitting the case to MARAC. (Please complete this section of the risk assessment with your observations about the service user’s level of risk, especially where there are lower numbers of ‘yes’ responses) Consider the victim’s situation in relation to children, disability, substance misuse, mental health issues, cultural/language barriers, honour based systems and minimisation. Are they willing to engage with your service, or any other support services? What are the victim’s greatest priorities in relation to their safety? :

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