Support Group

DOMESTIC VIOLENCE HISTORY AND ASSESSMENT
What is your relationship to the abuser?

MarriedIntimate PartnerDatingDivorcedSingle/Living TogetherSeparated
How long was the relationship
How long have you experienced abuse
Are there any children in common with the abuser?

YESNO
If yes, how many children?
Ages of children, if applicable

LEGAL HISTORY
Have you ever been arrested?

YESNO
If yes, reason for arrest
Date of arrest

MonthDayYear
Date
Are you on parole/probation?

YESNO
Parole/Probation officer name
Contact
Have you ever been ordered by the court to participate in mandated counseling or classes?

YESNO
Are you currently involved in any kind of litigation or legal dispute?

YESNO
If yes, please explain (i.e., custody dispute, dissolution proceedings, etc.)

MENTAL HEALTH HISTORY
Are you currently obtaining therapy such as individual or group therapy?

YESNo
If yes, please specify name
Contact
Are you currently experiencing depression/suicidal thoughts?

YESNO
If yes, please describe most recent episode
Have you recently been to a psychiatric hospital or day treatment center?

YESNO
If yes, please indicate when name of facility and duration of stay
Are you currently on any psychotropic medication?

YESNO
If yes, please list medication

PHYSICAL HEALTH HISTORY

Current physical health history or treatment (include present medical information and any accommodations if needed)
Are you currently on medication(s) for physical symptoms?

YESNO
If yes, current medication(s)

SUBSTANCE USE HISTORY
Have you recently been to an addition rehabilitation or recovery center?

YESNO
If yes, please indicate when, location, and duration of stay
Current substance use (i.e. street, OTC, non-RX pharma) or alcohol use?

YESNO
If yes, please indicate most recent use and whether it's daily, weekly, times per day

BASIC INFORMATION