Template library · Assessments & screeners
Domestic Violence Safety Screen template
Screen sensitively for current or past intimate partner violence.
Screen for intimate partner violence and safety risk
- 16 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Screening Items
- Current relationship involves physical harmTick box
- Current relationship involves threats or intimidationTick box
- Partner controls access to money, transportation, or communicationTick box
- Escalating frequency or severity of incidentsTick box
- Weapons present in the homeTick box
- Children present during incidentsTick box
Safety Planning
- Immediate safety needs identifiedText
- Referrals provided (shelter, legal, advocacy)Text
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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