Safety Planning - Risk Factors

1. Client believes abuser(s) may pose a danger to her, hospital her children and/or service providers   checkbox Yes     
checkbox No     
checkbox Unknown
2. Woman resides with the abuser checkbox Yes     
checkbox No     
checkbox Unknown
3. Client is considering or separated / estranged from abuser checkbox Yes     
checkbox No     
checkbox Unknown
4. Partner has threatened to hurt / harass / kill her, the children and / or themselves (threat of suicide or attempted suicide) if she leaves checkbox Yes     
checkbox No     
checkbox Unknown
5. Abuser has history of past assaults checkbox Yes     
checkbox No     
checkbox Unknown
6. Woman reports the violence has escalated checkbox Yes     
checkbox No     
checkbox Unknown
7. Damage or threat of damage to pets / property checkbox Yes     
checkbox No     
checkbox Unknown
8. Abuser has access to weapons checkbox Yes     
checkbox No     
checkbox Unknown
9. Abuser has history of substance abuse checkbox Yes     
checkbox No     
checkbox Unknown
10. Partner has threatened to take the child(ren) checkbox Yes     
checkbox No     
checkbox Unknown
11. Abuser displays obsessive or jealous behavior checkbox Yes     
checkbox No     
checkbox Unknown
12. Client is isolated from family and friends who know of the abusive behavior checkbox Yes     
checkbox No     
checkbox Unknown
13. Client has a new partner checkbox Yes     
checkbox No     
checkbox Unknown
14. Abuser suffers from depression and or other acute mental health problems checkbox Yes     
checkbox No     
checkbox Unknown
15. Client is in a common-law union with the abuser checkbox Yes     
checkbox No     
checkbox Unknown
16. There are ongoing child custody and access issues checkbox Yes     
checkbox No     
checkbox Unknown
17. The abuser is unemployed checkbox Yes     
checkbox No     
checkbox Unknown
18. There are step-children in the home checkbox Yes     
checkbox No     
checkbox Unknown
19. Client reports abuser to be forceful during sexual acts checkbox Yes     
checkbox No     
checkbox Unknown
20. Client is pregnant checkbox Yes     
checkbox No     
checkbox Unknown
21. Abuser chokes client checkbox Yes     
checkbox No     
checkbox Unknown
22. The woman is young (aged 15 - 29) checkbox Yes     
checkbox No     
checkbox Unknown
23. Abuser was exposed to woman abuse as a child checkbox Yes     
checkbox No     
checkbox Unknown
24. Client is homeless or at risk of becoming homeless checkbox Yes     
checkbox No     
checkbox Unknown
25. Client is a First Nations / Aboriginal woman, has a disability, is an immigrant checkbox Yes     
checkbox No     
checkbox Unknown
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