Domestic Violence Risk Assessment Form
Assessor Name
Date of Assessment
Victim Name/Identifier
Perpetrator Name/Identifier
Incident Details
Incident Date
Description of Incident
Risk Indicators
Has there been physical violence?
Yes
No
Has there been use or threats with weapons?
Yes
No
Has the victim expressed fear of the perpetrator?
Yes
No
History of prior domestic violence offenses?
Yes
No
Is there evidence of controlling or coercive behavior?
Yes
No
Children Involved
Are children involved?
Yes
No
If yes, details:
Other Concerns
Other risk factors / concerns
Recommendations / Actions