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?
*
Yes
No
Unsure/Don't Know
Has the current incident resulted in injury? - Comments
Are you frightened?
*
Yes
No
Unsure/Don't Know
Are you frightened? - Comments
Are you afraid of further injury or violence?
*
Yes
No
Unsure/Don't Know
Are you afraid of further injury or violence? - Comments
Do you feel isolated from family/friends?
*
Yes
No
Unsure/Don't Know
Do you feel isolated from family/friends? - Comments
Are you feel depressed or having suicidal thoughts?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/Don't Know
Have you separated or tried to separate from the perpetrator within the past year? - Comments
Is there conflict over child contact?
*
Yes
No
Unsure/Don't Know
Is there conflict over child contact? - Comments
Does the perpetrator constantly text, call, contact, follow, stalk, or harass you?
*
Yes
No
Unsure/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)?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/Don't Know
Is the abuse happening more often? - Comments
Is the abuse getting worse?
*
Yes
No
Unsure/Don't Know
Is the abuse getting worse? - Comments
Does the perpetrator try to control everything you do and/or are they excessive jealous?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/Don't Know
Has the abuser ever mistreated an animal or the family pet? - Comments
Are there any financial issues (dependence etc.)?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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?
*
Yes
No
Unsure/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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