Domestic Violence Risk Assessment Home Visit Form

General Information

Date of Visit Assessor Name Home Address Client Name Client Age

Family/Household Composition

List household members (Name, Age, Relationship)

Presenting Issues

Details of current concerns or incidents

Risk Factors

Physical Violence Present? Yes No Sexual Violence Present? Yes No Threats or Intimidation? Yes No Children at Risk? Yes No Other Risk Factors

Protective Factors

Describe any strengths, supports or protective factors

Assessment Summary

Summary of Risk Recommendations/Actions