LGBT Foundation - DASH RIC Form

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.
Service User Name*
Name of professional submitting form*
Name of organisation professional works for*
Has the current incident resulted in injury?*

YesNoUnsure/Don't Know
Has the current incident resulted in injury? - Comments
Are you frightened?*

YesNoUnsure/Don't Know
Are you frightened? - Comments
Are you afraid of further injury or violence?*

YesNoUnsure/Don't Know
Are you afraid of further injury or violence? - Comments
Do you feel isolated from family/friends?*

YesNoUnsure/Don't Know
Do you feel isolated from family/friends? - Comments
Are you feel depressed or having suicidal thoughts?*

YesNoUnsure/Don't Know
Are you feel depressed or having suicidal thoughts? - Comments
Have you separated or tried to separate from the perpetrator within the past year?*

YesNoUnsure/Don't Know
Have you separated or tried to separate from the perpetrator within the past year? - Comments
Is there conflict over child contact?*

YesNoUnsure/Don't Know
Is there conflict over child contact? - Comments
Does the perpetrator constantly text, call, contact, follow, stalk, or harass you?*

YesNoUnsure/Don't Know
Does the perpetrator constantly text, call, contact, follow, stalk, or harass you? - Comments
Are you pregnant or have you recently had a baby (in the past 18 months)?*

YesNoUnsure/Don't Know
Are you pregnant or have you recently had a baby (in the past 18 months)? - Comments
Is the abuse happening more often?*

YesNoUnsure/Don't Know
Is the abuse happening more often? - Comments
Is the abuse getting worse?*

YesNoUnsure/Don't Know
Is the abuse getting worse? - Comments
Does the perpetrator try to control everything you do and/or are they excessive jealous?*

YesNoUnsure/Don't Know
Does the perpetrator try to control everything you do and/or are they excessive jealous? - Comments
Has the perpetrator ever used weapons or objects to hurt you?*

YesNoUnsure/Don't Know
Has the perpetrator ever used weapons or objects to hurt you? - Comments
Has the perpetrator ever threatened to kill you or some else and you believed them?*

YesNoUnsure/Don't Know
Has the perpetrator ever threatened to kill you or some else and you believed them? - Comments
Has the perpetrator ever attempted to strangle, choke, suffocate, or drown you?*

YesNoUnsure/Don't Know
Has the perpetrator ever attempted to strangle, choke, suffocate, or drown you? - Comments
Does the perpetrator do or say things of a sexual nature that make you feel bad or that physically hurt you or someone else?*

YesNoUnsure/Don't Know
Does the perpetrator do or say things of a sexual nature that make you feel bad or that physically hurt you or someone else? - Comments
Is there any other person who has threatened you or who you are afraid of?*

YesNoUnsure/Don't Know
Is there any other person who has threatened you or who you are afraid of? - Comments
Do you know if the perpetrator has hurt anyone else?*

YesNoUnsure/Don't Know
Do you know if the perpetrator has hurt anyone else? - Comments
Has the abuser ever mistreated an animal or the family pet?*

YesNoUnsure/Don't Know
Has the abuser ever mistreated an animal or the family pet? - Comments
Are there any financial issues (dependence etc.)?*

YesNoUnsure/Don't Know
Are there any financial issues (dependence etc.)? - Comments
Has the perpetrator had problems in the past year with drugs, alcohol, or mental health which have affected their normal life?*

YesNoUnsure/Don't Know
Has the perpetrator had problems in the past year with drugs, alcohol, or mental health which have affected their normal life? - Comments
Has the perpetrator ever threatened or attempted suicide?*

YesNoUnsure/Don't Know
Has the perpetrator ever threatened or attempted suicide? - Comments
Has the perpetrator ever broken bail, an injunction, and/or formal agreement for when they can see you and/or children?*

YesNoUnsure/Don't Know
Has the perpetrator ever broken bail, an injunction, and/or formal agreement for when they can see you and/or children? - Comments
Do you know if the perpetrator has ever been in trouble with the police or has a criminal history?*

YesNoUnsure/Don't Know
Do you know if the perpetrator has ever been in trouble with the police or has a criminal history? - Comments
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