Domestic Violence Questionnaire

The purpose of a Domestic Violence Questionnaire is to determine what kind of danger the recipient of domestic abuse could be in.

Many factors weigh on a threat from a spouse or partner, and the Domestic Violence Assessment Test is a list of questions designed to determine whether a threat is real or simply a result of stress, unemployment, illegitimate children, etc.


Below is a brief set of screening questions found on a typical Domestic Violence Assessment test:

*** Start Domestic Violence Questionnaire ***

Assess the danger the victim is in:

____

Are you in danger right now?

____

Where is your domestic partner?

____

When you have finished receiving medical care, where will your domestic partner be?

____

Should the police be notified?

Determine the history and patterns of the abuse:

____

Has the violence been going on for a long time?

____

If so, how long? __________

____

Have you been harmed sexually by your partner?

____

Have your friends, pets, or family been harmed by your partner?

____

How much control does your partner have over your children, activities, or finances?

____

Determine whether there is a connection between your health and the domestic violence:

____

Is the violent or abusive behavior of your partner having an effect on your health?

(The above question could be for any sickness or medical condition, such as chronic back or neck pain, migraines, diarrhea or stomach pains, etc.)

____

Is the abusive behavior of your partner having an effect on your mental health?

(This includes signs of depression, suicidal tendencies, substance abuse, stress, etc)

Determine whether or not the victim is able to stay in contact with support groups or legal counsel:

____

In recent past, did you try different options for help?

____

Were the options you have tried so far useful in helping you deal with the problems?

____

Are you unable to stay connected to a support group or legal counsel that you can share your problems?

Determine whether the abuse could escalate into serious violence:

____

Is the abuse escalating, such as death threats, or the frequency and harshness of the abuse, substance abuse on the abuser's part, etc.

This domestic violence questionnaire has one goal in mind: to help the victim of domestic abuse and to ensure their continued well-being.

Assess Your Results:

____

Yes

(If you answered yes to any of these questions, you should find a shelter or domestic violence specialist to discuss your situation in more detail.)

____

No

(None of the above apply to me, or I choose not to answer the domestic violence questionnaire at this time.)

End of Questions.

If you answered "NO" in your assessment, should you reconsider the responses above?  Should you discuss the domestic violence questionnaire with a trained person? 

You or the victim that your are helping should be made aware of the fact that any domestic abuse is an infringement of legal rights, and legal action should be taken if the abuse continues.

Some people feel the need to cover for their domestic partner and excuse his or her actions, and they should be made aware of the fact that doing so is only continuing to harm them and their families. This enables the cycle to continue and become worse.

A more difficult situation occurs when a victim is isolated by the perpetrator or at risk of serious physical injury or death because of the level of escalation that has already occurred. Seek a professional to develop a strategy with you that can be successful in providing shelter and protection from extremely violent persons. The best strategy may be to literally tell everyone about what is going on. Call a Hotline and discuss this strategy.

Download a complete Domestic Violence Questionnaire.

Download the HITS tool for domestic violence assessment. Permission is required from the copyright holder before using the tool. Contact information is available on the form.

What is HITS? It is a very short 4 question domestic violence screening tool used around the world today. It has been translated into many different languages. HITS has been scientifically validated through many studies to be a promising and consistent tool for both men and women victims and useful in a variety of cultures.

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