DVIT Client Questionnaire
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (cell):
*
-
Area Code
Phone Number
Work Phone:
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Who is the identified victim?
*
What is their relationship to you?
*
What is the last working phone number you have for them?
*
What is their email?
*
example@example.com
Do you know where the victim lives?
*
Yes
No
Where they work?
*
Yes
No
Their daily schedule?
*
Yes
No
Did a court refer you?
*
Yes
No
Name of court:
*
Do you have a probation or parole officer?
*
Yes
No
Name of officer:
*
What is your current relationship status?
If you are currently in a relationship, what are your plans for the relationship?
Gender Identity:
*
Male
Female
Fluid
Non-Conforming
Questioning
Transgender
Transitioning
Two-spirit
Other
Pronouns you prefer:
*
He/him/his
She/her/hers
They/them/theirs
Other
If you’d like to share your sexual orientation
*
Your race
*
Your ethnicity
*
If you’d like to share your religion or spiritual belief
*
What groups do you belong to or identify with?
*
Past Experiences
Have you ever been the victim of domestic violence?
*
YES
NO
If yes, please explain:
Have you ever been the victim of sexual assault?
*
YES
NO
If yes, please explain whatever you’re comfortable sharing:
Have you ever been through what you would consider a traumatic experience?
*
YES
NO
If yes, please explain whatever you’re comfortable sharing:
Legal Considerations
Do you have any current court orders
No contact order
Protection order
Parenting assessment
Child support
Supervised visitation
Other
Are there past court orders that are no longer in effect?
*
YES
NO
If yes, please list them:
Have you ever been detained, arrested or charged for domestic violence?
*
YES
NO
If yes, how many times?
Were there ever any children present or in close proximity?
*
YES
NO
What would you like us to know about the most current incident(s)?
What would you like us to know about any of the past incidents?
SECTION 1:
Select any of the following situations that have ever been or are currently true for you:
The identified victim and I are separated.
I have caused physical harm to a partner.
I have put my hands on a partner’s neck when I was angry.
I have been controlling with a partner.
I have forced a partner to have sex with me.
I have tried to convince or pressure a partner to have sex with me when they didn’t want to.
I have been emotionally abusive to a partner.
I have been psychologically abusive to a partner.
I have used a firearm before.
I have training using firearms.
I have training using weapons other than firearms.
I have threatened to use a weapon on a partner.
I have used a weapon on a partner.
I have been a jealous person with a partner.
I have been possessive about a partner.
I have tried to isolate (keep them from spending time with friends or family) a partner.
I have monitored (cell phone, social media or in person) a partner.
I have physically kept a partner from leaving.
I have followed a partner or gone to where they are without their knowledge or permission.
I have abused or hurt an animal.
I have abused or hurt an elderly person.
I have abused or hurt a child.
I have recently lost my job or changed jobs.
I have recently broken up with someone.
I have recently started drinking or using drugs.
I have recently increased my drinking or drug use.
I have recently lost a friendship or other meaningful relationship.
The identified victim has children that are not biologically mine.
I have been violent before.
I have had police contact for my violence.
I have had an anger management assessment or treatment.
I have had a domestic violence assessment or treatment.
I have thought about suicide.
I have attempted suicide.
I have threatened to commit suicide.
I have thought about killing someone.
I have tried to kill someone.
I have threatened to kill someone.
I have violated a probation order, no contact order, protection order or similar order.
I have caused physical injury to someone.
I have committed a sexual assault.
I have strangled someone.
I have previous domestic violence incidents with more than one partner.
SECTION 2:
Have you ever had a traumatic brain injury?
*
YES
NO
If yes, please explain:
Have you had any history of concussions or brain disease or injuries from strokes or dementia?
*
YES
NO
If yes, please explain:
Have you had repeated blows to the head from sports or anything else, regardless of whether or not you lost consciousness?
*
YES
NO
If yes, please explain:
SECTION 3:
Select any of the items that you have experienced:
Direct or indirect exposure or witnessing of death, threatened death, serious injury or other violence
Easily startled or frightened
Recurrent and intrusive memories
Traumatic nightmares
Amnesia, forgetting who or where I am, sleepwalking or dream states
Self-destructive behavior
Constantly tense or on-edge
Irritability or aggressive behavior
Trouble sleeping
Overwhelming guilt or shame
Exaggerated startle response
Social isolation or withdrawal
Self-harm or suicidal thoughts or behaviors
Extreme shifts in mood
Intense emotional changes
Periods of mania and depression
Edginess
Restlessness
Excessive worry about topics, events or activities
Feelings of sadness, emptiness or hopelessness
A decrease of pleasure in activities
Significant weight loss or gain
Sleeping too little or too much
Feelings of worthlessness or inappropriate guilt
A decreased ability to think or concentrate
Compulsive, hostile or isolating behaviors
Impulsive behaviors
Feeling anxious, angry, guilty or lonely
Disrespect for the law and what society considers to be normal behavior
Rarely feel remorse or guilt
A tendency to be violent with those who I’m not close to
Trouble holding a steady job
Difficulty staying in one place very long
Close relationships with a specific person or a few people but difficulty feeling close with others
A dislike of society in general and its rules
Disorganized and spontaneous
A tendency to be nervous or easily agitated
Prone to emotional outbursts including rage
The ability to put myself in someone else’s shoes, like those I’m close to, but not with most people
Behavior problems in childhood
Not feeling attached to anyone
Easily gaining the trust of others
Easily manipulating others
Cool, calm and meticulous
Bold, not shy and mean
Impulsive and aggressive
Have you had previous mental health or domestic violence treatment?
*
YES
NO
If yes, where:
Are you currently attending any treatment?
*
YES
NO
If yes, where:
Do you have any mental health conditions we should be aware of?
*
YES
NO
If yes, what are they?
Are you currently taking any medications?
*
YES
NO
If yes, please list them:
SECTION 4:
What is your opinion about hierarchical relationships between intimate partners (where one person has more importance or more decision-making power over the other)?
*
What are your spiritual, religious and cultural beliefs about gender and family roles?
*
SECTION 5:
Have you used alcohol or any drugs?
*
YES
NO
If yes, please fill out the table and fill it in as needed:
Rows
Amount and frequency of use
Last date used
Alcohol
THC
Opiates
Cocaine
Meth
Have you ever had a substance related charge?
*
YES
NO
If yes, please explain:
Have you ever had a substance use assessment or treatment?
*
YES
NO
If yes, where (with approximate dates):
SECTION 6:
Please list your criminal history
Please include (Charge, Year, State & Outcome)
Have you lived outside of WA State over the last ten years?
*
YES
NO
If so, please list where (with dates):
Do you have friends or family who engage in criminal or illegal activities?
*
YES
NO
Do you have friends or family who are good influences on you?
*
YES
NO
If so, in what ways?
What is your current employment status (for how long)?
*
Do you enjoy your work?
*
YES
NO
Please explain:
What is your primary language?
*
Are you fluent in any other languages?
*
YES
NO
If yes, please list them:
Please list any learning disabilities, trouble reading or writing, or language needs:
*
Who are the people in your primary support group (your closest friends and family – your inner circle)?
*
How do the people in your primary support group feel about domestic violence and your current situation?
*
What motivates you to want healthy family relationships?
*
List some of your hobbies, recreational or social activities:
*
What are some of your personal strengths?
*
Submit
Should be Empty: