Domestic History Questionnaire
Excerpted from Ontario Domestic Violence Death Review Committee
Report to the Chief Coroner:
2005
NAME:___________________________________
INTERVIEWER:____________________________
OTHER:________________________________________________________________________________________________________________________________________________
In a domestic violence case, it is important to obtain detailed information about the specific incident. It is also critical to determine how the specific incident of violence relates to the overall history and context of abuse in your relationship. For this document, abuse includes emotional, verbal, financial, spiritual, as well as physical abuse. In this regard, it is necessary to consider several risk factors to determine the level of danger that may apply to your situation. Please voluntarily answer these questions, and use specific examples where applicable. If your answer is “yes” to any of these questions, please give details. Please attach additional pages if required. Please sign and date each page.
Please note: this document may be subject to disclosure and if there are criminal proceedings, it will be provided to the defence.
PRIOR ABUSE
1.Please circle the answers to the following questions:
Has your partner assaulted you, or been emotionally or sexually abusive with you, prior to this incident? Yes/ No
Has he/she ever forced you to have sex when you did not wish to do so? Yes/No
Has he/she ever choked you? Yes/No
If you have been pregnant, has your partner assaulted you during your pregnancy? Yes/No
Have you ever received medical attention as a result of being assaulted? Yes/No
Were there times when you should have sought medical attention but did not do so? Yes/No
If you answered yes to any of these questions, please provide details.
2.To the best of your knowledge, has your partner assaulted or been abusive to any other person (e.g. socially, to co-workers or strangers)? Please explain.
3.To the best of your knowledge, has your partner assaulted or been emotionally or sexually abusive with any previous spouse(s) /intimate partners(s), family members, or children from another relationship? Please describe. How did you acquire this information?
YOUR CHILDREN
4.How old are your children/stepchildren? Which children are from this relationship? Were any children present during this incident? Did they witness the incident? Were they directly involved in this incident? Have they been present for any prior incidents? Have the children ever seen you being hit before this incident occurred?
5.Have your children/stepchildren been assaulted, and/or have they experienced emotional or sexual abuse by your partner? How do they feel about your partner?
YOUR PARTNER
Stress
6. Is your partner experiencing an unusual degree of stress (family, financial, immigration, racism, homophobia, disability, work-related, medical, etc.)? How is your partner coping?
Isolation
7. Does your partner have friends, family, or outside agencies for support? Please list these persons. Do you think your partner’s support system, if any, helps or hinders your partner’s abusive behaviour? Is your partner isolated from others?
Children
8. Has your partner ever removed children from your care? Has your partner ever not returned children when required to do so? Has your partner attempted or threatened to do so? Is your partner using the children to control or influence you? Do you fear for the safety of your children in the presence of your partner?
Drugs and Alcohol
9. Does your partner use drugs or alcohol? How much and how often does your partner drink? Is your partner drunk every day or almost every day? What type of drugs are used and how frequently are they used? Is your partner addicted to any drugs, and if so, what drugs?
Mental Health
10. Is your partner under care for any mental health issues, or has your partner been under such care in the past? If so, for what? Does your partner suffer from any delusions, paranoia or depression? Explain.
11. Is your partner on any prescription medication? Please describe all prescription medications. Is your partner taking such medication as prescribed?
12. Has your partner ever participated in any treatment programs for alcohol/substance abuse or mental health issues? Has your partner ever refused to participate in such programs?
Counselling
13. Has your partner ever participated or received counselling in a program designed to deal with domestic violence? Please describe. What was your partner’s attitude about taking the program? Did your partner benefit from the program?
Court Orders
14. Has your partner ever failed to obey any past family or criminal court order (e.g., breach of restraining order, breach of bail condition, breach of probation, breach of parole)? Explain.
PROPERTY
15. Has your partner destroyed or damaged or threatened to damage: a) any of your belongings or contents of your home; b) property owned by your children, other family members, or friends?
PETS
16. Has your partner injured or killed a pet or domestic animal or threatened to do so?
PRIOR POLICE RESPONSE
17. Have the police been called to respond to any domestic situations involving you and your partner prior to this incident? What happened? What was your partner’s reaction? Were any other social services involved?
FIREARMS/WEAPONS
18. In the past has your partner owned or had access to any firearms or other weapons? If so, please describe the firearms/weapons and indicate whether they belonged to your partner or someone else.
19. Does your partner currently own or have access to any firearms or other weapons? If so, please describe these firearms/weapons, where they are presently located, and whether they are properly stored.
20. Has your partner ever possessed a firearms license or FAC (Firearms Acquisition Certificate)? Does your partner currently possess one? Where does your partner keep his/her firearms documentation?
21. Is your partner currently prohibited from possessing firearms? Has your partner ever been prohibited from possessing firearms? When and where did the prohibition order get made? When did it start, and if over, when did it end? When was the prohibition order made?
22. Is your partner familiar with the use of firearms or other weapons? Has your partner received any previous training (e.g. military, law enforcement)? Does your partner belong to any shooting clubs or ranges? Has your partner expressed an obsession or fascination with firearms or other weapons? Does your partner subscribe to or read any firearms or para-military publications?
23. Has your partner ever used, or threatened to use, firearms or other weapons on other occasions in the past? Explain.
SEPARATION
24. Have you ever separated or discussed separation with your partner? If so when? How is your partner reacting (e.g. aggressive, threatening, jealous, depressed, ect.)? Do you have any concerns for your safety?
CONTROLLING BEHAVIOURS
25. How does your partner behave with you? Please circle your answers.
Is your partner obsessed, jealous, or controlling with you? Yes/No
Has your partner ever confined you, or prevented you from using the telephone, leaving the house, going to work, or contacting family or friends? Yes/No
Does he/she control most or all of your daily activities? Yes/No
Does he/she tell you how much money you can use or when you can take the car? Yes/No
Does your partner withhold medical care or support? Yes/No
Are you dependent on your partner for attendant care or other daily needs? Yes/No
Are you sponsored by your partner or your partner’s family? Yes/No
Does he/she control your immigration documents? Yes/No
Has your partner threatened to “out” you to friends, co-workers, or family? Yes/No
Has your partner ever isolated you, intimidated you, or belittled you? Yes/No
If you answered yes to any of these questions please provide details.
26. To the best of your knowledge, has your partner displayed any of the behaviours listed in Question #25 in previous relationships? How are you aware of this information?
THREATS TO HARM
27. Has your partner ever threatened to kill you or harm you? In these threats, have there been specific details of a plan or method (e.g. a specific weapon or dangerous act)? Has your partner ever attempted to act on such threats?
28. Has your partner ever threatened to kill or harm other family members, children, friends, or helping professionals? In these threats, have there been specific details of a plan or method (e.g. a specific weapon or dangerous act)? Has your partner ever attempted to act on such threats?
29. Has your partner ever threatened or tried to commit suicide? If so, when? In these threats, have there been specific details of a plan or method (e.g., a specific weapon or dangerous act)?
STALKING BEHAVIOURS
30. Has your partner engaged in any of the following behaviours with you in the past? Please circle your answers.
Harassing phone calls or other communications to you, your friends, or family?
Yes/No
Watching, photographing or videotaping? Yes/No
Letter writing? Yes/No
Leaving notes? Yes/No
Frequenting your workplace? Yes/No
Following? Yes/No
Contacting you through third parties? Yes/No
If yes, when did they occur, and under what circumstances? Did any of these behaviors result in face-to-face contact?
31. To the best of your knowledge, has your partner engaged in any of the behaviours in Question #30 with any other person? When did this occur, and under what circumstances? If so, how did you acquire this information?
ESCALATION
32. Has there been an increase in severity and frequency of abuse, stalking and/or controlling behaviours, and/or threats to kill by your partner during the past year?
VICTIM’S FEARS AND CONCERNS
33. Do you believe your partner is capable of severely injuring or killing you (or your family or anyone else)? Do you believe your partner is capable of committing suicide? Do you have any fears for your safety, or the safety of others? What are your fears, and why?
If you are not aware of support services which may assist you with information, counselling, emergency shelter, and accommodation, please ask the interviewer who will assist you.
If circumstances have changed, or if you think of additional, relevant information, please immediately notify the interviewer, to update the information on this form.
_________ ________________
Date Victim’s Signature
___________________________________
Witness’s Signature
REFERRALS and SAFETY PLAN
NOT TO BE DISCLOSED
1. Do you have a personal safety plan in place to help protect you and your family in the event of a problem with your partner? If not, you may want to contact your local police service, women’s shelter, or community agency.
2. Are the local police, your neighbours, your employer, and your children’s school aware of any potential for problems?
3. Have you consulted a lawyer, or obtained a custody order or a restraining order?
4. Please provide a telephone number and address where you can be reached (home and work).
5. Please provide a telephone number and address of a friend or relative (home and work) who will know your whereabouts. |
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