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Steven Lawrence, 

Several risk factors have been associated with increased risk of homicides (murders) of women and men in violent relationships. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of abuse and for you to see how many of the risk factors apply to your situation. 

Using the calendar, please mark the approximate dates during the past year when you were abused by your partner or ex partner. Write on that date how bad the incident was according to the following scale: 

1. Slapping, pushing; no injuries and/or lasting pain 
2. Punching, kicking; bruises, cuts, and/or continuing pain 
3. "Beating up"; severe contusions, burns, broken bones 
4. Threat to use weapon; head injury, internal injury, permanent injury 
5. Use of weapon; wounds from weapon 

 (If any of the descriptions for the higher number apply, use the higher number.) 

Mark Yes or No for each of the following. ("He" refers to your husband, partner, ex-husband, ex- partner, or whoever is currently physically hurting you.) 
6. Does he threaten to kill you? 
 (If yes, was the weapon a gun? ) 
7. Has he avoided being arrested for domestic violence? 
8. Do you have a child that is not his? 
9. Has he ever forced you to have sex when you did not wish to do so? 
10. Does he ever try to choke you? 
11. Does he use illegal drugs? By drugs, I mean "uppers" or amphetamines, “meth”, speed, angel dust, cocaine, "crack", street drugs or mixtures. 
12. Is he an alcoholic or problem drinker? 
13. Does he control most or all of your daily activities?

For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? (If he tries, but you do not let him, check here: ) 
14. Is he violently and constantly jealous of you? (For instance, does he say "If I can't have 
you, no one can.") 
15. Have you ever been beaten by him while you were pregnant? (If you have never been 
pregnant by him, check here: ) 
16. Has he ever threatened or tried to commit suicide? 
17. Does he threaten to harm your children? 
18. Do you believe he is capable of killing you? 
19. Does he follow or spy on you, leave threatening notes or messages, destroy your 
property, or call you when you don’t want him to? 
20. Have you ever threatened or tried to commit suicide? 

 Total "Yes" Answers 

 Thank you. Please talk to your nurse, advocate or counselor about what the Danger Assessment means in terms of your situation. 
Domestic Violence Information:
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