Domestic Violence Lethality Assessment

Victim Information

Name Date of Birth Date of Assessment

Lethality Screening Questions

Has the suspect made threats to kill the victim or children?

Yes No

Has the suspect ever used or threatened to use a weapon against the victim?

Yes No

Has the suspect ever tried to choke or strangle the victim?

Yes No

Does the suspect have a firearm or access to firearms?

Yes No

Has the suspect ever threatened or tried to commit suicide?

Yes No

Has the violence increased in frequency or severity?

Yes No

Does the suspect control most or all of the victim's daily activities?

Yes No

Is the victim afraid the suspect will seriously injure or kill them?

Yes No

Has the suspect ever forced the victim to have sex?

Yes No

Additional Comments

Assessor's Name

Assessment Outcome / Referrals