• LGBT Foundation - DASH RIC Form

    Please explain that the purpose of asking these questions is for the safety and protection of the individual concerned. Please use the comment boxes after each question to expand on any answers if you respond 'yes'. If you wish to save your progress and return to the form later, there is a save button at the bottom of the form. You will be prompted to provide an email where a link will be sent to complete the form at a later time.
  • Has the current incident resulted in injury?*
  • Are you frightened?*
  • Are you afraid of further injury or violence?*
  • Do you feel isolated from family/friends?*
  • Are you feel depressed or having suicidal thoughts?*
  • Have you separated or tried to separate from the perpetrator within the past year?*
  • Is there conflict over child contact?*
  • Does the perpetrator constantly text, call, contact, follow, stalk, or harass you?*
  • Are you pregnant or have you recently had a baby (in the past 18 months)?*
  • Is the abuse happening more often?*
  • Is the abuse getting worse?*
  • Does the perpetrator try to control everything you do and/or are they excessive jealous?*
  • Has the perpetrator ever used weapons or objects to hurt you?*
  • Has the perpetrator ever threatened to kill you or some else and you believed them?*
  • Has the perpetrator ever attempted to strangle, choke, suffocate, or drown you?*
  • Does the perpetrator do or say things of a sexual nature that make you feel bad or that physically hurt you or someone else?*
  • Is there any other person who has threatened you or who you are afraid of?*
  • Do you know if the perpetrator has hurt anyone else?*
  • Has the abuser ever mistreated an animal or the family pet?*
  • Are there any financial issues (dependence etc.)?*
  • Has the perpetrator had problems in the past year with drugs, alcohol, or mental health which have affected their normal life?*
  • Has the perpetrator ever threatened or attempted suicide?*
  • Has the perpetrator ever broken bail, an injunction, and/or formal agreement for when they can see you and/or children?*
  • Do you know if the perpetrator has ever been in trouble with the police or has a criminal history?*
  • Should be Empty: