Instructions

This form must be completed for every female client whether or not you think there is violence. Interviews should take place in private, without partner or other family members present.

1) The domestic violence interview should take place at or within 30 days of intake.

A) If domestic violence is revealed at this time, fill out sections A (face sheet), B (interview), C (extent of domestic violence) and D (counselor's assessment).

B) If domestic violence is not revealed at this time, fill out sections A, B, and D.

C) Section E, the client assessment, should be completed after you and your client have had a chance to work together and not immediately after the domestic violence interview. Please wait at least 30 days (but not more than 90 days) before giving your client the assessment.

D) The case summary should be completed after the client has completed the client assessment.

Agency name:	Counselor's initials:	Code number:
Zip code of residency:	Race:	Religion:
Female Applicant	Age	Sex
Child 1	Age	Sex
Child 2	Age	Sex
Child 3	Age	Sex
Child 4	Age	Sex
Child 5	Age	Sex
Partner	Age	Sex	Relationship to Female Applicant
Does the partner reside in the home?	Yes	No
Others in household:	Age	Sex	Relationship to Female Applicant
Sources of Income	Employment	Income support	Social security	SSI	Other
Female Applicant
Partner

Section B Interview

We are interested in learning more about your family, its needs and how we might provide you with better services. We hope that you will be willing to answer the following questions in as much detail as possible.

1. Who is in you home (both those who live there or visit frequently)? Enter numbers and relationships (e.g. 2 sons, husband lives there, aunt visits twice a week):

2. There are arguments in all families. The following is a list of things couples have told us they most frequently argue about. How often do you and your partner argue about these things? For each subject, place an "X" under the appropriate description of frequency.

	Always	Almost Always	Usually	Sometimes	Never
Managing money
Cooking, cleaning, house work
Extended family/relatives
Social activities
Sexual relations
Discipline of the children
Things about the children
Drug or alcohol use
Other men/women
Pregnancy
Other (describe:)

3. Who usually has the last word in an argument between you and your partner?

4. Has an argument ever turned into a physical fight between you and your partner?

5. Has there ever been a physical fight during a pregnancy?

6. In general, how afraid are you of your partner?

7. Domestic violence is a problem that affects many families in NYC of all different races, religions and incomes. Many women are abused by their intimate partners in emotional, sexual, physical, and materials ways. For example, some partners hit, push, punch, or kick. Others threaten them with harm, withhold money from them, force them to do things they don't want to do, or constantly criticize them. Do things like this happen in your relationship with your partner?

8. Has your partner ever threatened to hurt you?

9. Has your partner ever threatened to hurt your children?

10. Have you ever left your partner, or tried to leave, because of domestic violence?

Section C Extent of Domestic Violence

1. In general where are the children when you and your partner fight?

2. How do the children react when you and your partner fight?

3. Does your partner prevent you from leaving home, using the telephone, seeking family/friends, or otherwise control your activities?

4. Does your partner destroy your possessions or hurt things you value, including household pets?

5. Is your partner under the influence of drugs or alcohol when he abuses you?

6. Has your partner ever threatened to harm himself?

7. Has your partner ever assaulted you (punched, kicked, hit, pushed)?

8. Does your partner ever force you to have sex?

9. Does your partner ever force you to engage in sexual activities (including preventing you form having safe sex or using contraception)?

10. Has your partner ever threatened to use a weapon against you (gun, knife, hammer, or other object)?

11. Has your partner ever used a weapon against you?

12. Have you other others ever called the police because of domestic violence?

13. Have you ever gone to a doctor or hospital due to injuries caused by your partner?

14. Do you ever use drugs or alcohol as a way to cope with the abuse?

15. Have you ever asked for help to stop the abuse, such as police, a court order, counseling, support groups, shelter, family, friends, clergy or other outside help?

16. Would you like help with safety planning for you and your children?

17. Do you want help in seeking a temporary battered women's emergency residence, court order of protection, support group, or any other services for you and your children?

Section D Counselor's Assessment

1. Did this case come to you with domestic violence as part of the referral?

2. Was there domestic violence in a prior relationship or in the family history?

3. Is there a reason to suspect domestic violence in this family even though the client did not reveal this information in the interview?

4. If domestic violence is a current problem, have you tried any of the following resources and what were the results?

Shelter

Hotline

Doctor or Hospital

Police

Legal Services

Court

Support Group

Counseling

Other

Section E Client Assessment

1. Do you feel that it was helpful to be asked questions about domestic violence?

2. Was there a way we could have asked the questions that would have been more helpful?

3. Was any of the information provided to you about domestic violence helpful to you or anyone else?

4. Do you feel that you have been able to better protect yourself because of conversations about domestic violence with your counselor?

5. Do you feel that you have been able to better protect your children because of conversations about domestic violence with your counselor?

6. How can we be more helpful in dealing with domestic violence in your family?